Journal of Nursing, Social Studies, Public Health and Rehabilitation

České Budějovice 2011 JOURNAL OF NURSING, SOCIAL STUDIES, PUBLIC HEALTH and rehabilitatioN ISSN 1804-1868 (print); ISSN 1804-7181 (online)

Editor-in-Chief: Brook University Medical Center, Stony Brook, New Prof. Miloš Velemínský, MD, PhD, Czech Republic York, USA Prof. Claus Muss, MD, PhD, International Society of Deputy Chief Editors: Applied Preventive Medicine, Vienna, Austria Prof. Peter Fedor-Freybergh, MD, PhD, St. Elisabeth Peter Ohnsorge, MD, European Academy for University College of Health and Social Work, Environmental Medicine, Würzburg, Germany Bratislava, Slovak Republic; Editor-in-Chief, Carolyn Santora, MS RN CNAA-BC, Associate Neuroendocrinology Letters, Stockholm, Sweden Director, Patient Safety & Regulatory Affairs, Stony Prof. Vilém Kahoun, MA, PhD, University of South Brook University Medical Center, Stony Brook, New Bohemia, Faculty of Health and Social Studies, York, USA České Budějovice, Czech Republic Eric Scott Sills, MD, FACOG, FACS, Editor-in-Chief, Lucie Kozlová, PhD, University of South Bohemia, Journal of Experimental and Clinical Assisted Faculty of Health and Social Studies, České Reproduction, Dublin, Ireland Budějovice, Czech Republic Prof. Ladislav Šoltés, MD, DSc, St. Elisabeth University Adéla Mojžíšová, MA, PhD, University of South College of Health and Social Work, Bratislava, Bohemia, Faculty of Health and Social Studies, Slovak Republic České Budějovice, Czech Republic Judith M. Stefano, RN, BS, Patient Safety Nurse Prof. Valérie Tóthová, MA, PhD, University of South Coordinator, Patient Safety & Regulatory Affairs, Bohemia, Faculty of Health and Social Studies, Stony Brook University Medical Center, Stony České Budějovice, Czech Republic Brook, New York, USA Marek Šusta, PhD, First Faculty of Medicine, Charles Board of Associate Editors: University, Prague, Czech Republic Prof. Elvidina Adamson-Macedo, PhD, Charted Prof. Michele Trimarchi, PhD, President, International Health Psychologist, University of Wolverhampton, Society of Neuropsychophysiology, Rome, Italy Wolverhampton, United Kingdom Fridtjof Andersen, MD, General Practitioner, Oslo, Board of Editors: Norway Věra Adámková, MD, PhD, University of South Prof. Thomas Endler, MD, Head, Medical Laboratory Bohemia, Faculty of Health and Social Studies, Dept., Kaiserin Elisabeth Hospital of the City České Budějovice, Czech Republic Vienna, Vienna, Austria Magdalena Drábová, PhD, University of South Prof. Tobias Esch, MD, Head, Division of Integrative Bohemia, Faculty of Health and Social Studies, Health Promotion, Coburg University of Applied České Budějovice, Czech Republic Sciences, Coburg, Germany Prof. Leoš Navrátil, MD, PhD, Czech Technical Prof. Štefan Galbavý, MD, PhD, DSc, Vicepresident University in Prague, Faculty of Biomedical of University and Head of Institute, St. Elizabeth Engineering, Kladno, Czech Republic University of Health and Social Sciences; Institute Prof. Jozef Novotný, MD, PhD, University of South of Laboratory Medicine, Faculty of Medicine, Bohemia, Faculty of Health and Social Studies, Comenius University, Bratislava, Slovak Republic České Budějovice, Czech Republic Peter Hajduk, MD, Surgeon, Researcher, Aura Medical Daniel Prouza, MA, PhD, University of South Clinic, Prague, Czech Republic Bohemia, Faculty of Health and Social Studies, Prof. Vladimír Krčméry, MD, DSc, St. Elisabeth České Budějovice, Czech Republic University College of Health and Social Work, Jana Šemberová, MA, PhD, University of South Bratislava, Slovak Republic Bohemia, Faculty of Health and Social Studies, Paolo Lissoni, MD, Divisione Radioterapia Oncologica, České Budějovice, Czech Republic Ospedale S. Gerardo, Monza, Italy Jiří Šimek, MA, PhD, University of South Bohemia, Torstein Lyberg, MD, DDS, PhD, Center for Clinical Faculty of Health and Social Studies, České Research, Ullevaal University Hospital Oslo, Norway Budějovice, Czech Republic Prof. Michael Maes, MD, PhD, Clinical Research Miroslav Šíp, MA, DSc, University of South Bohemia, Center for Mental Health, Antwerp, Belgium Faculty of Health and Social Studies, České Prof. Spiridione Masaraki, MD, PhD, Ospedale Budějovice, Czech Republic Niguarda Ca’granda, Milan, Italy Jitka Vacková, PhD, University of South Bohemia, Prof. Jozef Mikloško, MD, PhD, St. Elisabeth Uni- Faculty of Health and Social Studies, České versity College of Health and Social Work, Bratislava, Budějovice, Czech Republic Slovak Republic Miloš Velemínský, Jr., MD, PhD, University of South Barbara M. Mills, RN, DNP, ACNP, ANP, PNP, CCRN, Bohemia, Faculty of Health and Social Studies, PCCN, Director, Rapid Response Team, Stony České Budějovice, Czech Republic CONTENTS 137 155 174 165 139 212 219 138 198 190 229

...... Original articles ATTITUDE TO HEALTH IN MEMBERS OF THE MONGOLIAN MINORITY IN THE CZECH REPUBLIC Valérie Tóthová, Věra Veisová, Helena Michálková, Monika Jelečková OF THE INFANT Claus Muss Reviews DEVELOPMENT NUTRITION ON THE CEREBRAL IMPACT OF PRENATAL Peter G. Fedor-Freybergh, Lili Maas Peter G. Fedor-Freybergh, Laudatio Editorial Peter G. Fedor-Freybergh NTS CONTE POSSIBILITIES OF USING THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF) BY GONIOMETRY AND MUSCLE TESTING IN PHYSIOTHERAPY Zuzana Drábová, Marek Zeman, Miriam Ištoňová, Ludmila Brůhová PRENATAL PERIOD OF LIFE AS A MATRIX FOR OUR LIVES AND OUR SOCIETIES – PRENATAL PERIOD OF LIFE AS A MATRIX A CULTURAL-PSYCHOLOGICAL SPECULATION Ludwig Janus. MORE THAN NEIGHBORS: A COMMON BASIS FOR RELATIONSHIP-CENTERED MORE THAN NEIGHBORS: A COMMON MEDICINE AND SCIENCE Hans von Lüpke. STATE-CONTRIBUTORY SUPPLEMENTARY CURRENT PROBLEMS OF THE CZECH PENSION INSURANCE Jan Molek, Martin Šimák, Petra Molková oL ISSUES IN THE DEFINITIONS OF HRQ Elena Gurková. HISTORICAL DEVELOPMENT OF PROSTITUTION IN EUROPE AND ITS IMPACT HISTORICAL DEVELOPMENT OF PROSTITUTION ON THE CZECH REPUBLIC Roman Bláha AND NITROSAMINES IN NUTRITION SIGNIFICANCE OF NITRATE, NITRITE Miroslav Stransky THE ISSUE OF DIAGNOSTICS OF CHILDREN CEREBRAL PALSY IN RELATION TO PROVISION OF HEALTHCARE IN THE DISTRICT OF TEPLICE Dana Šlechtová...... 239

CHILD SUICIDE IN THE CZECH REPUBLIC FROM 2002–2009 Dominika Průchová...... 255

MOTIVATION FOR USING ILLEGAL DRUGS AT FREETEKNO PARTIES Alena Kajanová, Aneta Klečacká...... 264

Information for contributors...... 270 Journal of Nursing, Social Studies, Public Health and Rehabilitation, Vol. 2, No. 3–4, 2011, pp. 133–274

EDITORIAL

I write this Editorial on behalf of the Austrian publisher of this journal, the foreign members of the Board of Associate Editors, and myself. You hold in your hands the second double issue of this year, complementing the two years of very successful existence of this journal. When this journal started in spring 2010, there was a vision of interdisciplinarity, integration of different disciplines, internationality and of high scientific quality and integrity. Looking through the published issues during these two years, we agree that this vision was successfully completed. We now have a journal with high scientific quality of articles, with integration of social care and health care, and above all, with emphasis on psychosocial rehabilitation,

which was from the beginning stressed by the Editor-in-Chief, Professor Veleminsky. EDITORIAL This psychosocial rehabilitation offers a bridge between healthcare and social care, which consists of primary, secondary and tertiary prevention (Milos Veleminsky, editorial Vol. 2 No. 1–2, 2011). In 2012 it is our aim to get this journal included in several prominent databases and significantly increase the amount of contributions from colleagues in Europe, USA, Asia and other overseas countries. This journal has already found a great deal of international interest and the opinions of distinguished institutions from abroad were all positive and encouraging. In my first editorial in Vol. 1 No. 1–2, 2010, I wished this journal a good and safe journey. This wish became fulfilled in an excellent manner, its journey is good and safe, rowed in safe waters with secure hands of the Editor-in-Chief, Professor Veleminsky. All of us are confident and convinced that the future of this journal is secured and prepared for continued success.

Peter G. Fedor-Freybergh Deputy Chief Editor, Stockholm, Sweden

137 Laudatio

Professor Milos Veleminsky, MD, PhD, Dr.h.c. 75th Anniversary (*14. 8. 1936)

– a long lasting, good and faithful friend, Editor- in-Chief of this journal, former Dean (2004–2011) of the Faculty of Health and Social Sciences, South Bohemian University in Ceske Budejovice, Czech Republic – currently holding the Chair of clinical and preclinical disciplines there. Professor Veleminsky worked within neonatology since 1969 in which field he still is very active both clinically and scientifically. He published valuable papers in the fields of neonatology, preventive and social pediatrics, rehabilitation, and psychosocial care of disabled children, further within prevention of accidents in children and their relation to family constellation, and recently also about health and social situation of immigrants and refugees in the Czech Republic. In 1976 he built the first neonatal intensive care unit for newborns in South Bohemia, which developed into a modern department for newborn and premature babies, which he chaired between 1983–1997. He also founded registering genetic defects in the South Bohemian region and included the medical genetics into general pediatric praxis. Professor Veleminsky is a big-hearted, compassionate, generous and caring man of great grace. As a pediatrician in private practice in his home town of Trebon, he is hugely appreciated and loved by his fellow citizens. In this activity which he devotes himself from all of his heart in addition to his academic work at the university, he would never refuse to treat a sick child even during nights and weekends, any time. Once, when visiting his hometown, we met several mothers who told us to watch the kids on the street, with a comment “... without Dr. Veleminsky only half of them would be alive”. One of his great devotions is the rehabilitation of child patients. To this end he developed a very successful and lovely canis therapy unit, primary for autistic and mentally handicapped children. Prof. Veleminsky founded the Journal of Nursing, Social Studies, Public Health

LAUDATIO and Rehabilitation where he holds a position as Editor-in-Chief and is a member of several editorial boards – International Journal of Prenatal and Perinatal Psychology and Medicine, Neuroendocrinology Letters, and Activitas Nervosa Superior Rediviva. His interest in prenatal and perinatal psychology and medicine resulted in the founding of the Czech Society in this field, and was appointed its President. He also became the Honorary Board Member of the Institute of Prenatal and Perinatal Psychology and Medicine at the St. Elisabeth University College of Health and Social Work, the world’s first universitybased Institute and Chair in this field. Dear Milos, we from the Editorial Boards of the Neuroendocrinology Letters and the International Journal of Prenatal and Perinatal Psychology and Medicine, would like to thank you for your great contribution to the humanities and for your concern about children’s health and welfare of all ages both in illness and health, from all walks of life and backgrounds. Stay well our dear friend, we wish you many future years of good health, eternal interest in science and research, continuous curiosity “pour les choses de la vie”, and a lot of fun and joy of each day with your wonderful and supporting wife, with your son, a senior obstetrician and gynecologist, with your daughter, a successful physiotherapist, with many good friends, and last but not least with your lovely dogs. Peter G. Fedor-Freybergh and Lili Maas Editors-in-Chief, Neuroendocrinology Letters and International Journal of Prenatal and Perinatal Psychology and Medicine

138 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 139–154

IMPACT OF PRENATAL NUTRITION ON THE CEREBRAL DEVELOPMENT OF THE INFANT

Claus Muss

International Scientific Group of Applied Preventive Medicine (I-GAP), Research Center and Laboratory, Vienna, Austria

Reprinted: Int J Prenat Perinat Psychol Medicine 22(1–2): 13–32

Submitted: 2011-10-11 Published online: 2011-12-15

Abstract It is well documented that malnutrition in pregnancy is of increasing concern in both the developing and developed world, resulting in poor health of children. Various serious diseases in childhood have been attributed to malnutrition in maternity. Latest research links maternal malnutrition with dysfunction of the higher brain in children. It has been hypothesised from animal trials, that prenatal nutrition has a strong impact on the neurological development of the infant. Especially the content of unsaturated fats and certain phospholipids seem to be essential for the cerebral function of the REVIEW foetus. There is a strong body of evidence pointing especially to omega 3 fatty acids and choline as one very necessary nutritional component in pregnancy. The consumption of omega 3 in fish has been under controversial discussion because of methyl mercury which can induce food poisonings also affecting the unbo0rn child. Evidently mother’s nutrition is effecting the development of the child even after parturition. However little is only known about the definite supply with choline in different stages of human pregnancy. Considering factors socioeconomically, it can be assumed that choline supply in pregnant woman presently does not meet the required amount for a development of higher brain structures in children. This certainly applies to developing countries with a higher proportion of poverty and malnutrition in low-income households. Epidemiological data has shown, that in so called developed countries such as in Europe or United States the content of choline in prenatal diets is not balanced enough to reach the requirements of the unborn child fully. From this point of view the prevention of prenatal malnutrition is a main subject for public health concern. We recommend revising the rationale for recommending certain dietary supplements in pregnancy and breastfeeding women.

Key words: nutrition in pregnancy; impact of malnutrition on intelli- gence in children; stimulating components in food for the development of intelligence; omega 3 and choline and cerebral development

INTRODUCTION certainly is a special stage of metabolism requiring a higher amount of macro- and It is well documented that malnutrition micronutrients. Recommendations have in pregnancy is of increasing concern in been made on the basis of this observation both the developing and developed world, emphasising the special need for different resulting in poor health of children. A large vitamins. Primary care and National body of evidence proves that pregnancy Health Services should be instructed and

139 Claus Muss well aware about the appropriate diets and size, and cardiovascular disease was later supplementation of pregnant women. In confirmed in many epidemiological studies, some countries the benefit of healthy vitamin including in the USA and in India. A further starters for pregnant women as supplements factor of non communicable chronic disease including folic acid, vitamins C and D have such as the metabolic syndrome and diabetes been widely accepted (NICE 2008). II seem to be related with prenatal intrauterine Supplementation has many potential malnutrition. Insulin resistance associated advantages over fortification and dietary with small size at birth was frequently shown approaches for improving micronutrient to be present at a young age. Although intake. Pregnant and lactating women and there are still controversial areas, there is at infants are most likely to benefit from such present sufficient scientific evidence for foetal supplementation. This has been proved for programming to be regarded as an additional vitamin A, ferum and folate. Even UNICEF risk factor for chronic disease, in interaction has been employing the supplementation in with genetic and lifestyle risk factors. The certain programmes aimed at the prevention fact that intrauterine growth retardation low birth weight (Shrimpton et al. 2002). may predispose to nutrition-related chro- Late discovery about some effects of nic disease has serious implications. The nutritional compounds in pregnancy on challenge is for programmes to simultaneously dividing progenitor cells has broaden the combat apparently opposite nutrition approach for finding other critical nutrients. problems, malnutrition and “over-nutrition”. More human studies need to be conducted to Improving the nutrition of women is even increase epidemiological evidence. A better more imperative when considering that it may understanding of diet and diet supplement contribute to preventing chronic diseases in intake during pregnancy and lactation the next generation, in addition to enhancing is needed to prove the bioavailability of health and survival of mothers and children certain critical nutrients. Also, a deeper (Delisle 2002). understanding of common genetic variations Aspects of prenatal malnutrition in influencing nutrient requirements during developing and so called developed countries these periods is also needed for clarification will be discussed in this review socio- the premises of sufficient prenatal nutrition. epidemiologically and from a point of view of Supplementation of maternal and infant diets Preventive medicine. Biochemical pathways of calls for more understanding about the risks critical nutrient components will be discussed of having insufficient critical nutrient supply. and different potions of intervention will be Whatever the limitations of the current state summarized to face the problem of prenatal of knowledge, it is apparent that pregnancy malnutrition in the interest of public health in and lactation are periods during which good future. nutrition is exceptionally important. The infant is not protected from the inadequate Socio-epidemiological aspects of diet of the mother (Zeisel 2009). prenatal malnutrition in developing Supplementation in pregnancy is of countries utmost concern in Public Health, with no The consequences of food and nutrition regional exception. Intrauterine growth shortfalls are enormous. Protein-energy retardation, which reflects in large part malnutrition can impair the immune maternal malnutrition, contributes to chronic system, leaving malnourished children less disease risk through foetal programming. able to battle common diseases. Again the Foetal programming implies that during combination of malnutrition and infectious critical periods of prenatal growth, permanent disease can be particularly in particular changes in metabolism or structures result pernicious (Tomkins and Watson 1989). from adverse intrauterine conditions. Obser- Malnutrition reduces work capacity and vational studies first showed an association the immune system, both of which affect between lower birth weights and higher rates income generation. Women and children who of coronary disease in the 80s, in England have special nutritional needs are particularly and Scandinavia. The link between low birth at risk. Food shortages are known to impact weights, or other indicators of small birth most acutely on women during pregnancy.

140 Impact of prenatal nutrition on the cerebral development of the infant

Maternal malnutrition, poor foetal growth financial crisis in 1997–98 wasting increased and stunting in the first two years of life lead to in Javanese women, although without increased maternal and child mortality as well increases in child malnutrition, suggesting as causing irreversible damage throughout that mothers buffered children’s food intake. the course of life, such as shorter adult height, Moreover, increased prevalence of anaemia lower attained schooling, reduced adult in mothers and children was associated with income and decreased offspring birth weight a reduction in consumption of high quality among those that survive (Victora et al. 2008). foods. The combined effects were particularly Such malnutrition in developing countries severe for cohorts conceived and weaned is strongly linked to poverty. According to the during the crisis (Block et al. 2004). world resources institute approximately 800 Africa, the Andean region of South million people i.t. one out of every 5 people in America, and many parts of Asia are at risk the developing world did not have access to from not only protein energy malnutrition, enough food for healthy living (FAO 1996). but also from all three main micronutrient In developing countries, presently 40 per- deficiencies because of both poverty and cent of nonpregnant women and 50 percent environmental factors. Iron deficiency is of pregnant women are found to be anaemic, the most common micronutrient disorder. and 3.6 billion people suffer from iron Whereas women are usually the last to benefit deficiencies. The problem is most severe in from increased household income they are India, where 88 percent of pregnant women usually the first to make sacrifices when the are anaemic (The World Health Report 1997). financial situation deteriorates (State of the Overall the number of extremely poor is World’s Children 2007). estimated to have increased by between 130 The Centre for International Health, and 155 million globally between 2005 and Division of Health Sciences, Curtin University 2008, with another 53 million more expected of Technology, Perth, Western Australia, by the end of 2009. It may be assumed that Australia studied the maternal malnutrition the first response is to save on food costs and in rural Bangladesh which belongs to the cut down on non-staple food consumption in poorest areas in the world. They found developing countries. These coping strategies that despite high levels of awareness of affect first the diversity and quality, and then nutritional dietary requirements, half the the quantity and safety of diets, with mothers women reported unchanged or reduced food usually the first to make such sacrifices. intake during pregnancy. Dietary taboos Distress sales of assets and cutbacks in health and food aversions were widely practiced. expenditures may further jeopardize the Women consistently received the last and nutrition situation. It can be expected that smallest food shares during mealtimes. This malnutrition of pregnant women increases in data proves that pregnant women although developing countries such as Africa and Asian in a special position of nutritional need are continent in future dramatically. often the last members of the food chain in The risk of poverty and its effects on developing countries (Shannon et al. 2008). prenatal nutrition may even increase under The Erasmus University Rotterdam, the present aspect of the global financial crisis. Netherlands studied the socioeconomic Food shortages are known to impact most inequality in childhood malnutrition in the acutely on women during pregnancy. The developing world, to provide evidence for an Dutch famine of 1944–45 showed for instance association between socioeconomic inequality that even in a previously well nourished and the average level of malnutrition. In population receiving food rations, even minor almost all countries investigated, stunting food restriction during pregnancy produced and wasting disproportionately affected significant reductions in birth weight, length the poor. Socioeconomic inequality in and head circumference (Stein and Susser childhood malnutrition existed throughout 1975). the developing world. Failure to tackle this Recent evidence from developing country inequality is a cause of social injustice. settings further confirms that raising food According to the authors reducing the overall prices contributes to maternal and child rate of malnutrition does not necessarily malnutrition rapidly. During the Indonesian lead to a reduction in inequality. Policies

141 Claus Muss should, therefore, take into account the The Department of Basic Medical Sciences distribution of childhood malnutrition across of the University of the West Indies, Kingston all socioeconomic groups (Van de Poel et al. Jamaica, examined the dietary intake of 2008). choline in groups of students at the University Another example of malnutrition has been of the West Indies. Sixty-two medical students under investigation by the Department of (first and second years) and biochemistry Community Medicine, Medical College, New students (final year) were recruited The Delhi, India documenting the current dietary analysis revealed that 86.2% of the females profile of pregnant women in rural areas of and 90.9% of the males reported diets that Delhi. The mean intake of macronutrients delivered less daily choline than the adequate and micronutrients, namely, iron, folic acid intake quoted by the Institute of Medicine and Vitamin C which play an important role of the National Academy of Sciences, USA in the pathophysiology of nutritional anaemia (425–550 mg/day). The dietary intake of during pregnancy was calculated from the choline in the majority of students were below foodstuffs, using Nutritive Value of Indian adequate intake. It can be concluded that the Foods. The intake of calories, protein, iron, part of population at a special need such as folic acid and vitamin C was found to be less pregnant women have to face even a greater than the recommended dietary allowance gap of choline supply (Gossell-Williams and of pregnant women respectively. Folic acid Benjamin 2006). intakes were significantly lower in younger, This data highlights the need to address primiparous and poorly educated women traditional dietary taboos and preferences, from low-income families. The overall data and actively target key household decision suggested the presence of food gap rather than makers, namely, husbands and mothers- isolated deficiency of any particular nutrient in-law, in nutrition behaviour change (Guatam et al. 2008). communication. The Department of Paediatrics and Child Socioepidemiological aspects of Health, Ile-Ife University, Nigeria assessed prenatal malnutrition in developed four hundred and seventy three live born countries neonates for foetal malnutrition and found Chronic diseases are the main public health a relatively high rate Eighty-nine 18.8% of problem in Western countries. There are the 473 babies with foetal malnutrition. indications that these diseases originate in the Severe birth asphyxia, respiratory distress, early childhood or even have prenatal roots. It meconium aspiration, hypoglycaemia, high is thought that malnutrition of the fetus during haematocrit and hypoalbuminaemia were critical periods of development would lead to significantly commoner in babies with foetal adaptations in the structure and physiology of malnutrition. Infants with foetal malnutrition the fetal body, and thereby increase the risk of had significantly higher mortality and diseases in later life. neurological sequelae in the first month Although a lot has been undertaken to of life. Finally they concluded that foetal cope with nutritional needs of pregnant malnutrition is a major health problem in women by social public health systems Nigeria with considerable morbidity and epidemiological data still refers to a resisting mortality (Adebami et al. 2007). lack in this regard. This tendency may even While this epidemiological data on increase under the aspect of further economic pregnant women proves a lack in vitamin depression. intake in developing countries only little is European records have shown that known about the supply with essential fats malnutrition during gestation affects health in such population. A study from the Human in later life. This was proven by the historical Nutrition and Food Science Department, disaster of the Dutch famine. According California Poly Pomona revealed an to this epidemiological data, the effects of insufficient supply with phosphatidylcholine malnutrition, were depending upon the in African American women lately, which was specific time of gestation. adult health associated also with lower folate status (Hung without affecting the size of the baby at birth et al. 2008). (Roseboom et al. 2001).

142 Impact of prenatal nutrition on the cerebral development of the infant

Studies clearly proved that small variations efficiency of conversion of dietary to tissue within the normal range in the micronutrient energy. content of maternal diets and/or maternal If averaged over 280 days, the cumulative micronutrient status during pregnancy are energy cost of pregnancy is about 300 kcal per associated with significant differences in day. However during the first quarter there is foetal and infant growth. relatively little gain of fetal or maternal tissue This was shown by randomized controlled and the daily additional need is thought to trials in Cleveland Ohio, USA which be only about 115 kcal per day. During the increased mean birth weight by 200 g in a next two quarters extra energy is needed iron-folate supplementation versus a true primarily for maternal tissue accretion placebo in non-anaemic women during the which is primarily fat. This averages about latter part of pregnancy. It was concluded 380 and 420 kcal per day in the second that even in so called developed countries and third quarter, respectively. Fetal tissue maternal malnutrition and the premature gain is great in the fourth quarter, but since introduction of complementary foods with maternal gain is considerably reduced, the low energy-nutrient density lead to low birth average daily cost is only about 320 kcal. Data weight, impaired growth and intellectual compiled from several studies of basal energy development, and high mortality. Finally expenditure (BEE) during pregnancy show an more than 5 million of the 10 million annual average increase of approximately 20% over child deaths are attributed to malnutrition non pregnant rates, with a range of 13 to 48 (Friis 2006). percent (King 1981). A survey of the actual nutrition status Despite these calculations present studies of the urban population of the Primorsky have shown that healthy pregnancy and Krai Territory (Russia) revealed the under- the development of the foetus require more consumption of choline containing milk and than mere energy consideration. Vitamins, its products, eggs, meat and its products, and minerals and trace elements are known to be in contrast overconsumption of fish and its essential in pregnancy. Sufficient supply with products, bread and bakery products, and critical nutrients is linked to some degree with vegetable oil. The assessment of the nutrient the density of energy consumption. However composition of foodstuffs indicated that all amino acids and proteins as well as essential the population groups showed the varying fats and phospholipids need a separate levels of vitamins A, D, B12, beta-carotene consideration. and the inadequate content of pantothenic To guarantee optimal supply with essential and folic acids, choline, calcium, magnesium, food components during pregnancy prenatal iodine, zinc, selenium. Although such surveys nutrition should not be limited to calculations can not fully represent the nutritional status in based on a caloric scale. Later data has developed countries, it may be assumed that shown that the quality of food, measured by certain parts of the population have to cope the contents of minerals, trace elements and with a lack of choline supply in pregnancy vitamins are of utmost importance for the (Lapardin and Kiku 2008). developing the foetus. A sufficient prenatal nutrition can be Essential components of adequate defined only on the basis of a balanced nutrition in maternity energy intake and an adequate supply with Malnutrition has often been linked with micronutrients essential for the intrauterine a shortage of energy consumption. From development. To date, however there is still the viewpoint of energy, pregnancy is a only very small clinical data about essential physiological stage of high turnover in energy. amino acid phospholipids needs during It has been calculated that the total energy pregnancy. cost of pregnancy is about 85,000 kcal. Three It has been estimated that the cumulative components comprise the total cost: the total gain of protein in the fetus and maternal energy equivalent of the fat and protein gained body is about 925 g. Since fetal growth occurs in the fetus and added maternal tissues, the primarily in the last half of gestation, predicted energy required to support metabolism of nitrogen accretion is considerably greater the these added tissues, and an allowance for last 20 weeks than the first 20 weeks. The

143 Claus Muss mean nitrogen retention during the last half child (see Table 1 below). The body’s folic of gestation is 860 mg per day; retention over acid increases during pregnancy. Folic acid all of gestation averages 530 mg N per day. deficiencies during pregnancy have been In conclusion, it seems that in the first half of linked to low birth weight and to an increased gestation measured N storage is three to six incidence of neural tube defects (such as times greater than the predicted gain. At least spina bifida) in infants. Most healthcare 36 kcal per kg are required during pregnancy professionals recommend that women of for support of N retention (Oldham and Sheft childbearing age supplement with 400 to 1951). Until further data are available, it seems 800 mcg per day. Folic acid should be taken prudent to assume that the rate of N storage is even before a woman knows she is pregnant constant throughout gestation and is at least and throughout the entire pregnancy. Folic- 1.0 g per day (Hitten 1980). acid supplementation is important prior to To support a gain of 1.0 g N or 6.25 g conception because it provides its protection protein per day with a 30 percent efficiency in the first weeks of pregnancy before a of utilization, 20 additional g protein are woman knows she has conceived. Vitamin B12 needed in the diet. If an additional 30 percent can cause anaemia and irreparable damage is added to cover individual variability, to the nervous system. Vegans (people who the incremental dietary protein need for eat no animal products), including those who pregnancy is about 25 g. Thus, a reference are pregnant, should take a daily vitamin pregnant woman consuming a diet with a B12 supplement. Low maternal vitamin B12 protein score of 70 should add 25 g protein levels are more commonly seen in smokers to the 41 recommended for the nonpregnant and are associated with low birth weights state bringing the total to 66 g protein per and premature birth. The recommendation day. Latest recommendations from the D-A- of daily allowance (RDA) of vitamin B12 for CH organisation now even referred to 1,3 g/kg pregnant women is 2.6 mcg per day from all body weight as a sufficient protein supply from sources. Lactating women require 2.8 mcg per the 4. month of pregnancy. This corresponds day (Böhm et al. 2003, Böhm and Muss 2011). with 78 g protein in pregnant women with Women who have taken oral contraceptives 60 kg (Joint FAO/WHO... 1973). during the months prior to pregnancy may be Several nutritional components have been also at increased risk of vitamin B6 deficiency. traced to be essential for pregnant woman. Vitamin B6 is essential for neurotransmitter Folic acid, vitamin B12, vitamin B6 vitamin synthesis and is a coenzyme of many enzymes D are regarded among other substances vital related to cerebral functions (Böhm et al. for the cerebral development of the unborn 2003, Böhm and Muss 2011).

Table 1. Vitamins needed in non pregnant and pregnant woman according to D-A-CH recommendations

Vitamin Non pregnant women Pregnant women Vitamin A 0,8 mg >1.1 mg Vitamin D 5 µg 5 µg Vitamin E 12 mg >13 mg

Vitamin B1 1 mg 1.2 mg

Vitamin B2 1,2 mg 1.5 mg

Vitamin B3 13 mg 15 mg

Vitamin B6 1.2 mg 1.9 mg

Vitamin B12 3 µg 3.5 µg Folic acid 0.4 mg 0.8 mg Vitamin C 100 mg 110 mg

144 Impact of prenatal nutrition on the cerebral development of the infant

Among minerals calcium, iron and zinc, synapses. It serves as a catalytic component were described to have an essential impact of over 200 enzymes and as a structural on gestation (see Table 2). The highest risk component of various proteins, hormones, for iron deficiency occurs in the last weeks and nucleotides. Growing evidence suggests of pregnancy. Healthy nonpregnant women that zinc may also be a key mediator and should not supplement with iron unless they modulator of the neuronal death associated have an iron deficiency proven by a blood with transient global ischemia and sustained test. Many, but not all, pregnant women seizures, as well as perhaps other neurological eventually require iron supplementation disease states (Hurley and Swenerton 1966, during pregnancy, usually around 45 mg per Hambidge et al. 1986, Valle and Falchuk 1993, day. Pregnant women may help increase the Choi and Koh 1998, Krebs 2000). birth weight of their babies by taking iron Zinc deficiency alters autonomic nervous supplements before 20 weeks’ gestation. system regulation and hippocampal and However it should be kept in mind that cerebellar development (Georgieff 2007). Zinc heavy supplementation of iron diminishes deficiency has been related to hyperactivity in zinc bioavailability. Women may become children (Mehmet et al. 2006). marginally zinc deficient during pregnancy, In summary, the data strongly suggest that particularly if they are supplementing with zinc supplementation improves the pregnancy greater than 30 mg per day of iron. Studies outcome in at least some pregnant women, conflict as to whether zinc supplementation and the inclusion of zinc in prenatal mineral is effective or necessary in well-nourished tablets should be approved. The minimum pregnant women (Böhm et al. 2003, Böhm dosage of zinc for any population of pregnant and Muss 2011). women is not known, although in the present Vegetarians may have subtle nutritional study beneficial effects were demonstrated deficiencies which have been related to the with a daily supplement of 25 mg. Zinc occurrence of an unrecognized malabsorption supplementation should be under a control of syndrome. The excess phytate content in medical experts (Böhm et al. 2003, Böhm and cereals, nuts, legumes and oilseeds which Muss 2011). represent the mainstay of their food intake, Beside these critical components in seems to play a central role in the pathogenesis prenatal nutrition also fats play a decisive of this malabsorption syndrome as an inverse role in protection brain functions of the child relationship has been shown to link the in pregnancy. Especially brain development phytate content of the diet with the intestinal seems to depend on a sufficient supply absorption of zinc and proteins (Krebs 2000, with lipid vital substances. However as Böhm et al. 2003, Böhm and Muss 2011). shown above only little is known about the Zinc is also regarded an essential catalytic supply with these substances in pregnancy or structural element of many proteins, and epidemiologically. To our opinion, this matter a signalling messenger that is released by of prenatal nutrition has not been regarded neural activity at many central excitatory with enough emphasis in the past.

Table 2. Minerals needed in non pregnant and pregnant woman according to D-A-CH recommendations

Mineral Non pregnant women Pregnant women calcium 1000 mg 1200 mg magnesium 300 mg 310 mg ferum 15 mg 30 mg

iodine 200 µg 230 µg

145 Claus Muss

Omega 3 fatty acids yet too weak, as most of the studies reviewed It is becoming common knowledge that had small sample sizes and were conducted omega3 fatty acids are exceptionally important in clinically diagnosed samples, with no for human health. placebo-controlled groups (Ramakrishnan et Omega3 and omega6 fatty acids are labelled al. 2009). ‘essential’ because the body cannot synthesize Recommendation for fish consumption in them on its own. During foetal development, prenatal diets is presently strongly debated, omega3 fatty acids are especially important as it seems that a larger fish consumption is for neural development and cell growth. associated with a higher risk of food poisoning Throughout pregnancy, omega3’s supply by methylmercury. Excessive toxic metal essential lipids to the foetus, as important absorption seems to be liable with higher fish brain and eye development takes place during consumption as fat depots of sea fish are often foetal development, continuing well into loaded with heavy metals (Department of the child’s infant years. Omega3 fatty acids Environment Food... 2006). during pregnancy and during the formative Soluble methylmercury has been shown years after birth have been discovered to be to invade fatty tissues and long-term foetal a critical element for both the neurological exposure during pregnancy and may therefore and visual development of the baby. DHA is contribute to irreversible developmental especially vital, as foetus cannot produce DHA disorders. Transplacental transmission of efficiently independently. cadmium, lead and mercury have been proven Studies have proven that supplementation in the past also in humans (Semczuk and with very-long-chain n-3 fatty acids during Semczuk-Sikora 2001). pregnancy and lactation can even augment Officially pregnant woman have been children’s IQ in early years of age (Helland et warnde by the US Department of Health al. 2003). and Human Services, US Environmental Unfortunately in most Western lifestyles Protection Agency not to exceed their fish our diets include dangerously low levels of consumption above 340 g/week (The US omega3s and a level of omega 6 fatty acids Department of Health... 2004, Myers and that is far too high. Fish is known to contain Davidson 2007). a higher amount of omega 3 fatty acids. Over In contrast to the recommendation of US the past thirty years, the focus of this research has turned to omega 3 fatty acids and their Department of Health the ALSPAC study role in the behavioural development and produced only results in favour of higher fish learning skills. ADHD, in particular, has been consumption in pregnancy. Maternal seafood very closely associated with omega 3 fatty acid consumption of less than 340 g per week in deficiency both in terms during pregnancy pregnancy did not protect children from and in the infant’s diet until at least the age adverse outcomes; rather, beneficial effects of four. Research has shown that infants with on child development with maternal seafood lower omega 3 levels are more likely to suffer intakes of more than 340 g per week were behavioural problems including hyperactivity, recorded. This suggests that limiting seafood impulsivity, anxiety, temper problems and consumption could actually be detrimental. unsettled sleep patterns (Kodas et al. 2004). These results show that risks from the loss of This tendency was proved by another nutrients were greater than the risks of harm study group showing that abnormal essential from exposure to trace contaminants in 340 g fatty acid profiles were often observed in seafood eaten weekly (Hibbeln et al. 2007). younger children and distinctly different Recent studies in the Seychelles have from normal controls of similar age. Further focused on nutrients in fish that might fatty acid differences were not explainable by influence a child’s development, including differences in intake. The group suggested long-chain polyunsaturated fatty acids, that there are metabolic differences in fatty iodine, iron, and choline. Preliminary findings acid handling between ADHD adolescents from this study suggest that the beneficial and normal controls (Colter et al. 2008). influence of nutrients from fish may counter On the other side it has been criticized, any adverse effects of MeHg on the developing that evidence from intervention trials was nervous system (Myers et al. 2007).

146 Impact of prenatal nutrition on the cerebral development of the infant

It is important to remember that it is and sphingomyelin. The outer leaflet of easier for pregnant women to experience a plasma membrane is rich in these choline- deficiency in omega 3 fatty acids because phospholipids whereas the inner leaflet is more essential fatty acids are required to dominated by phosphatidylethanolamine, build a growing baby. This deficiency can be phosphatidylserine, and phosphatidylinositol. compounded in subsequent pregnancies due Phosphatidylcholine, the predominant to the fact that maternal stores can become phospholipid (>50%) in most mammalian further depleted with each pregnancy, rarely membranes, not only contributes to the returning to pre-pregnancy levels (Scientific structure of the membrane bilayer, but Advisory Committee on Nutrition... 2004). products of receptor-mediated lecithin Insufficient intakes of omega-3 fatty acids hydrolysis also serve as important second during pregnancy have been associated with messengers in signal cascades that control cell intrauterine growth retardation, delayed or growth and gene expression. suboptimum depth perception, adverse neuro Phosphatidylcholine, which is a polar development, residual deficits in fine motor lipid, is present in commercial lecithin in skills, speed of information processing in concentrations of 20 to 90%. Most of the infants, and irreversible deficits in serotonin commercial lecithin products contain about and dopamine release. Studies show that 20% phosphatidylcholine. maternal dietary n-3 fatty acid deprivation Choline is an essential nutrient that is impairs foetal brain DHA accretion and critical during fetal brain development. PS metabolism; altered PS metabolism Choline deficiency may alter DNA methylation may change release of lipid mediators and and thereby influence neural precursor cell neurotransmitter precursors important in proliferation and apoptosis. This results in brain function (Salem et al. 2001, Calderon long term alterations in brain structure and and Kim 2004, Daniels et al. 2004, Scientific function, specifically memory function. The Advisory Committee on Nutrition... 2004, choline requirement can be met via endogenous Tom and Innis 2006). de novo synthesis of phosphatidylcholine catalyzed by phosphatidylethanolamine N-methyltransferase (PEMT) in the liver. Table 3. Nutritional sources of Omega 3 Though many foods contain choline, many ______humans do not get enough in their diets. • Krill Oil This evidently applies especially for pregnant • Walnuts & Oil women (Fischer et al. 2007). • Flax & Oil The definite amount of choline needed in • Wild Alaskan Salmon nutrition can not be determined and it has to be • All oily fish • Chia Seeds anticipated that there is an individual need for • Hemp choline. The adequate intake recommendation • Marine algae of 550 mg choline/d was established for ______the prevention of liver dysfunction in men, as assessed by measuring serum alanine aminotransferase concentrations (Veenema Choline et al. 2008). Choline, a dietary component of many However further studies have shown that foods, is part of several major phospholipids the amount of endogenous choline supply (including phosphatidylcholine – also called varies according to the activity of hormones lecithin) that are critical for normal membrane and the genetic influence. Estrogen induces structure and function. As a major precursor expression of the PEMT gene and thereby of betaine, it is used by the kidney to maintain allows premenopausal women to increase water balance and by the liver as a source of choline supply endogenously. This might methyl-groups for methionine formation. explain a certain protection in pregnancy. Also, choline is used to produce the important However a significant variation in the dietary neurotransmitter acetylcholine. In the body requirement for choline can be explained by choline is mainly found in phospholipids, common genetic variants (single nucleotide such as lecithin (phosphatidylcholine) polymorphisms; SNPs) in genes of choline

147 Claus Muss and folate metabolism. Some of these increase Supplementation with choline during the risk of choline deficiency many-fold. These embryonic days in rats improves memory variations in choline requirement could have performance in adulthood and protects important implications for brain development against age-related memory decline, whereas (Resseguie et al. 2007, Zeisel 2008). choline deficiency impairs certain cognitive Choline tresspasses diaplacental into fetal functions. It was previously reported that blood circulation. Choline is concentrated global and gene-specific DNA methylation in fetal blood 14× more than in maternal increased in choline-deficient fetal brain blood stream. Breast milk contains choline and liver, and these changes in DNA concentrated by factor 100 in comparison to methylation correlated with an apparently maternal blood. Weaned babies are supplied compensatory up-regulation of the expression by breastmilk naturally from the mother with of DNA methyltransferase Dnmt1. In a 20 mg choline/kg/d. Choline helps to increase further study, pregnant rats were fed a diet the number of cells in the memory center containing varying amounts of choline. The during a critical period of brain development mRNA and protein expression of histone in pregnancy. methyltransferases G9a and Suv39h1 were Study results from the Department of directly related to the availability of choline. Nutrition, School of Public Health and School DNA methylation of the genes was up- of Medicine, University of North Carolina regulated by choline deficiency, suggesting USA revealed that a choline-deficient diet that the expression of these enzymes is under increased DNA damage also in humans. negative control by methylation of their genes. Assessment of DNA damage and apoptosis in These data show that maternal choline supply lymphocytes appeared in choline deficiency during pregnancy modifies fetal histone and (Da Costa et al. 2006). DNA methylation, suggesting that a concerted Evidence is growing that optimal dietary epigenomic mechanism contributes to the intake of choline and folate (both involved long term developmental effects of varied in one-carbon transfer or methylation) is choline intake in utero (Zeisel 2009b). important for successful completion of fetal The effects of prenatal choline availability development. Significant portions of the on Pavlovian conditioning were assessed in a population are eating diets low in one or both study with adult male rats. Prenatal choline of these nutrients. As it is well documented, availability significantly altered the contextual folates are important for normal neural control of these learned behaviors. Both tube closure in early gestation, and the control and choline-deprived rats exhibited efficacy of diet fortification with folic acid context specificity of conditioned excitation as in reducing the incidence of neural tube exhibited by a loss in responding when tested defects is a major success story for public in an alternate context after conditioning; health nutrition. Similarly, maternal dietary in contrast, choline-supplemented rats choline is important for normal neural tube showed no such effect. When switched to closure in the fetus and, later in gestation, a different context following extinction, for neurogenesis in the fetal hippocampus, however, both choline-supplemented and with effects on memory that persist in adult control rats showed substantial contextual offspring; higher choline intake is associated control of responding, whereas choline- with enhanced memory performance. deficient rats did not. These data support the Although both folates and choline have many view that configural associations that rely on potentially independent mechanisms whereby hippocampal function are selectively sensitive they could influence fetal development, these to prenatal manipulations of dietary choline 2 nutrients also have a common mechanism during prenatal development (Lamoureux et for action: altered methylation and related al. 2008). epigenetic effects on gene expression (Davison Another animal trial proved the effects et al. 2009, Zeisel 2009a). of choline supplementation on the interval- Via its metabolite betaine, choline serves timing ability and temporal memory of as a donor of methyl groups used in fetal the offspring. Psychometric response development to establish the epigenetic functions indicated that prenatal-choline DNA and histone methylation patterns. supplementation systematically increased

148 Impact of prenatal nutrition on the cerebral development of the infant sensitivity to auditory signals relative to visual (Lymphocyte Transformation Test LTT) signals, thereby magnifying the modality (Muss et al. 2009). effect that sounds are judged to be longer than This is in concordance with further lights of equivalent duration. In addition, results from studies investigating the sensitivity to signal duration was greater in association between dietary choline and rats given prenatal-choline supplementation, betaine consumption and various markers particularly at low intensities of both of low-grade systemic inflammation. the auditory and visual signals. Overall, Participants who consumed a higher amount these results suggest that prenatal-choline of choline enriched food had lower signs supplementation impacts interval timing of inflammation in this trial. These results by enhancing the differences in temporal support an association between choline integration between auditory and visual intakes and the inflammation process in stimuli in aged subjects (Cheng et al. 2008a). free-eating and apparently healthy adults An animal trial with rats further showed (Detopoulou et al. 2008). In vertebrates how increased choline availability during the choline supplementation even contributed to second half of gestation presumably produces restoration of defective myelination (Szalay et long-lasting cognitive effects. Rats that obtain al. 2001). supplemental choline during embryonic day had enhanced depolarization-evoked Table 4. Nutritional sources of choline acetylcholine (ACh) release from hippocampal ______slices, whereas choline deficiency during this • beef liver time reduced this release. Rats whose mothers • chicken liver consumed a choline-supplemented diet had • eggs a higher level of insulin-like growth factor II • wheat germ • bacon (IGF2) mRNA. IGF2 is known to stimulate • pork endogenous ACh release (Napoli et al. 2008). • dried soybeans A further animal experiment showed that ______choline supplementation increases striatal nerve growth factor expression in mice, Recommendations for choline reach food suggesting that neuronal proliferation and for pregnant woman have to consider that fatty survival may contribute to improved motor acid makeups of phosphatidylcholine from performance (Nupur et al. 2008). plant and animal sources differ. Cattle liver, To further delineate the impact of cooked beef contains 400 mg per 100 grams early nutritional status, the Department on an average, cornflakes contain 170 mg per of Psychology and Neuroscience, Duke 100 grams listed and an egg contains 125 mg. University, North Carolina USA examined Saturated fatty acids, such as palmitic and effects of prenatal-choline supplementation stearic, make up 19 to 24% of soya lecithin; on timing, emotion, and memory performance the monounsaturated oleic acid contributes of adult male and female rats. In summary, 9 to 11%; linoleic acid provides 56 to 60%; long-lasting effects of prenatal-choline and alpha-linolenic acid makes up 6 to 9%. supplementation were exhibited by reduced In egg yolk lecithin, the saturated fatty acids, frustrative responding in conjunction with palmitic and stearic, make up 41 to 46% of the persistence of temporal memory and egg lecithin, oleic acid 35 to 38%, linoleic acid enhanced temporal exploration and response 15 to 18% and alpha-linolenic 0 to 1%. Soya efficiency (Cheng et al. 2008b). lecithin is clearly richer in polyunsaturated Besides these data from neurophysiologic fatty acids than egg lecithin. Also poppy-seed studies we were able to prove in own studies an oil (5%) contains considerable amounts of anti-inflammatory effect of i.v choline citrate lecithin (choline) (Roeytenberg et al. 2007). infusions in patients with multiple sclerosis in an earlier clinical trail. We hypothesized that choline citrate may increase ATP and perfusion CONCLUSIONS in CNS and regulates lymphocyte activity. Our patients showed significant response to In pregnancy there is evidently a higher risk choline i.v. treatment by lymphocyte reaction for malnutrition especially in poverty and for

149 Claus Muss women living in regions with less structured brain and have no serious side effects when public health systems. Children born under consumed in pregnancy (Hunter et al. 2008). such circumstance seem to gain a higher risk Besides certain vitamins i.t. folic acid and for cerebral dysfunction as certain nutritional vitamin B12 pregnant women should therefore components definitely bear a strong impact be advised to focus on minerals (zinc) and to on the cerebral development. make sure, that the eat enough essential fats This review encourages public health and phospholipids. After parturition baby systems in general to focus on prenatal food should be also enriched with choline nourishment of pregnant women in order containing least 10–30 mg/150 ml choline. to avoid possible impairment of cerebral Prior to pregnancy or at least as early as development in children. possible within pregnancy the individual Brain consists of 60 percent fat. Omega 3 health status should be determined by fatty acids are essential, but unfortunately are professional experts. In case of signs of associated with a certain risk of heavy metal malnutrition we suggest to control the exposure. Choline supplements are also very following parameters by blood work (Table 5): essential for the development of the child’s

Table 5. Blood parameters suggested in malnutrient pregnancy (Böhm et al. 2003)

Parameter of malnutrition Material Normal range Folic acid Serum 4–17 g/l Ferritin Serum Male: 60–160 g/dl; Female: 40–140 g/l Homocysteine Serum Serum <12 µmol/l Zync Full blood (Erythrocytes) 4–7.5 mg/l (0.09–0.11 mmol/l)

A steady increase in plasma choline are provided commercially. In turn rising meets an inverse tendency of Homocysteine choline levels contribute to an attenuation of levels advancing in gestation. There seems Homocysteine levels (Selhub 1999, Ozarda et to be a concurrent attenuation of the al. 2002). Other critical factors of malnutrition Folate-Homocysteine relation, especially in such as folic acid, zinc and ferritin should midtrimester. Thus, both mobilization of also be under the control in pregnancy to maternal choline stores and enhanced de novo implement an individual tool of prophylaxis choline synthesis may cause maternal plasma for cerebral dysfunction in the infant. choline concentrations to rise. However, We encourage further epidemiological the net effect may be the diminution of studies in this regard to add more evidence maternal choline reserves in the second half to our hypothesis of the beneficial effects of pregnancy. The steady increase in plasma of choline supplementation in pregnancy. choline throughout gestation may ensure Such study design should also enhance the choline availability for placental transfer, with understanding on Homocysteine levels and subsequent use by the growing fetus. This choline supply in pregnant women clinically. relation also points to the possibility that a low betaine and choline status may predispose to Nutrition has a strong impact on the pregnancy complications associated with high development of the infant and according Homocysteine (Holm et al. 2005). to the revealed evidence therefore should We therefore recommend to control be considered the basis for prevention of choline status in pregnancy by measuring neurological dysfunction in infants. The data Homocysteine levels. Homocysteine levels presented, proves that nutrition has a long- may rise in choline deficiency (Shaw et al. lasting decisive impact on the development 2004). Measuring Homocysteine is well of the intelligence of children. Prenatal diets established and Homocystein measuring kitts should therefore not only be assessed on the

150 Impact of prenatal nutrition on the cerebral development of the infant basis of caloric sufficiency. Pregnant women For the sake of omega 3 supply fish is a should consult with their doctor at the very important component of prenatal diets. beginning of prenatal care to determine how Pregnant woman are further recommended best to meet their specific nutritional needs. to feed on milk, eggs or meet to satisfy their Besides well known effects of folic acid and daily choline supply if possible. Alternatively zinc pregnant woman should regard special on behalf of public health concern we fatty acids such as omega 3 and other products suggest to offer pregnant woman soybean (phospholipids) containing choline for extracts in order to avoid deficient choline themselves and there babies as very essential. supply. Lecithin preparations in tablet form Vegetarians who renounce milk and eggs have show on average 13% of choline content. a risk of choline deficiency. These women Side effects may not be expected from oral should consider soybean food to satisfy their choline supplementation. Recommended needs. dosage of choline is about 3,5 grams per Soybean, sunflower and rapeseed are the day. This may combined with Vitamin B12 major plant sources of commercial lecithin. and folic acid. Public Health Institutions Soybean however is the most common source. should revise their recommendations for Plant lecithins are considered to be GRAS supplementation in pregnancy including the (generally regarded as safe). Egg yolk lecithin above mentioned features for the benefit of is not a major source of lecithin in nutritional the cerebral development of the infant in supplements. Eggs themselves naturally future generations. contain from 68 to 72% phosphatidylcholine, while soya contains from 20 to 22% phosphatidylcholine.

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61. The World Health Report (1997). Conquering Suffering, Enriching Humanity 51 World Health Organization (WHO). 62. Tomkins A, Watson F (1989). Malnutrition and Infection: A Review (United Nations Administrative Committee on Coordination/Subcommittee on Nutrition, WHO, Geneva, 5–6. 63. Vallee BL, Falchuk KH (1993). The biochemical basis of zinc physiology. Physiol Rev. 73: 79–118. 64. Van de Poel E, Hosseinpoor AR, Speybroeck N, Van Ourti T, Vega J (2008). Socioeconomic inequality in malnutrition in developing countries. Bull World Health Organ. 86(4): 282–291. 65. Veenema K, Solis C, Li RW, Wei M, Charles VA, Christian M, Caudill MA (2008). Adequate Intake levels of choline are sufficient for preventing elevations in serum markers of liver dysfunction in Mexican American men but are not optimal for minimizing plasma total homocysteine increases after a methionine load. Am J Clin Nutr Sep. 88(3): 685–692. 66. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HS (2008). Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 371(9609): 340–357. 67. Zeisel SH (2008). Genetic polymorphisms in methyl-group metabolism and epigenetics: lessons from humans and mouse models. Brain Res. 1237: 5–11. 68. Zeisel SH (2009a). Importance of methyl donors during reproduction. Am J Clin Nutr. 89(2): 673– 677. 69. Zeisel SH (2009b). Is maternal diet supplementation beneficial? Optimal development of infant depends on mother’s diet. Am J Clin Nutr Feb. 89(2): 685–687. 70. Zeisel SH, Mar MH, Howe JC, Holden J (2003). Concentrations of choline-containing compounds and betaine in common foods. J. Nutr. 133: 1302–1307.

 Contact: Claus Muss, International Scientific Group of Applied Preventive Medicine (I-GAP), Research Center and Laboratory, Währingerstr. 63, A-1090 Vienna, Austria E-mail: [email protected]

154 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 155–164

PRENATAL PERIOD OF LIFE AS A MATRIX FOR OUR LIVES AND OUR SOCIETIES – A CULTURAL-PSYCHOLOGICAL SPECULATION

Ludwig Janus

Schröderstr. 85, 69120 Heidelberg, Germany

Reprinted: Int J Prenat Perinat Psychol Medicine. 22(1–2): 33–45, 2010

Submitted: 2011-10-24 Published online: 2011-12-15

Abstract The personal historical significance of the prenatal and perinatal period has been researched and described at the individual level by prenatal psychology in many ways. The collective psychological significance of the prenatal and perinatal period has also been repeatedly reflected upon by individual prenatal psychologists without these thoughts receiving wider notice. The following contribution is therefore to gather together again important aspects of this topic, whereby “physiological premature birth”, REVIEW typical of humans, receives special attention.

Key words: prenatal psychology; psychohistory; history; culture

INTRODUCTION “This biological moment (the reduction of the intrauterine existence) poses the first danger situation and creates the need to be loved that will In psychoanalysis and prenatal psychology never leave humans.” conjectures are frequently made Sigmund Freud about how our perinatal and perinatal experiences influence our later life. Today [“Dies biologische Moment (der Verkürzung a lot of information is available from self- der Intrauterinexistenz) stellt also die erste awareness groups in which it is possible Gefahrensituation her und schafft das Bedürfnis, geliebt zu werden, das den Menschen nicht mehr to make early pre-verbal experiences verlassen wird”] (Freud 1926, p. 168). accessible again by using certain techniques (Ridgeway and House 2006). Furthermore there is practical knowledge from the treatment of patients who had to positive experiences which in contrast to bear particular stresses in the period to negative experiences, however, cannot before or during birth. These observations be so easily identified in later experiences gave the impression that the prenatal and and behaviour, as is the case in negative perinatal experiences can accompany our experiences. Nevertheless, they are also of lives and experiences like a background equal, if not greater, significance. film and can co-determine our actual There have always been considerations experiences and behaviour. An example in psychoanalysis and prenatal psychology would be a fear of destruction resulting about how these influences work at from experiencing a deadly threat in the the collective level. Here I would like prenatal period or fear of change resulting to give some names, the list of which from a traumatic birth. Such experiences is not exhaustive: Freud, Jung, Rank, have a formative influence and can subtly Graber, Mott, Lake, DeMause, Fedor- affect actual experience and behaviour. Freybergh, Dowling, Crisan, Blazy, This of course applies in the same way Wasdell, Fabricius, Sloterdijk, Evertz

155 Ludwig Janus and many more. However these observations neglected starting point, with which I will and considerations have hardly received therefore begin. attention in wider circles. This is associated with the particular difficulty of internally The anthropological and psychological comprehending pre-verbal experiences significance of “physiological because we are centred in our experience of premature birth” our verbal ego and this limits our perception. The tangible and obvious biological distinction Whereas memory research was based earlier of humans in comparison with other primates on the assumption that only verbal memory is, along with bipedalism and brain size, the existed, nowadays it is generally accepted striking and long-lasting helplessness of that pre-verbal and non-verbal recollection of human infants. The biological background perceptions, feelings and pictures is of similar is the so-called “physiological premature significance (Shachter 1994). However, our birth” (Portmann 1969, Gould 1992), the common sense is still totally centred on speech psychological consequences of which for the and its scope as Wittgenstein is supposed collective experience will be elaborated on to have pragmatically formulated: “If you here. Due to the extreme helplessness caused can’t talk about it, you have to be silent.” The by this premature birth, the human infant apparent brilliance of this statement appears lives in a dual world. It lives on the one hand today from the point of view of prenatal in the shelter of primary parental care and psychology as a perception restricted by the relationship that replaces the womb: it is fed, prevailing era. In fact the pre-verbal and warmed, carried around and cared for with non-verbal world of experience has the same the intimacy of bodily proximity and contact; significance as the verbal world. Language has on the other hand it lives in the external world made increasingly larger areas of the external and is exposed to its influences. Therefore world as well as the internal world accessible the primary protection and total care of the in the course of historical development. We parents who replace the security of the prenatal can encompass verbally more and more world is important for its survival. Because details of the external world. And this is also the human infant cannot cling to its mother the case for the internal world of our feelings as it is too weak and she possesses no fur, it and perceptions. Poets have in the course of has to achieve and secure its place through history verbally expressed more and more relationship and it does this with eye contact, areas of our inner experiences. Especially in mimic, gesture and vocal pleas (Morgan 1995). the modern era, when one thinks of Kafka The fine co-ordination shows itself amongst or Beckett, increasingly refined means of others in the contented infant’s movements to expression for pre-verbal and non-verbal the rhythm of the mother’s voice, which can experiences were developed. This is the also be seen well when it is lying and the mother case with modern painting which, whether bends over and talks to it. This co-ordination abstract or surrealist, in its way tries to in the movements also exists before birth express not yet verbally formulated depths and it has been called a “foetal dance”. In (Evertz and Janus 2001). this fine co-ordination of movements and In this way the pre-verbal and non-verbal feelings of attachment, which were only world gradually begins to impinge on our recognised to their full extent through films consciousness. However, because as already of mother-child interaction, a part of the stated the prenatal and perinatal parts of primary entity before birth is restored after our biographies are still little perceived birth. The child is able in contact with the by common sense, I want in the following mother to reproduce emotionally something contribution to reassemble some aspects of the union of the primary situation. This which will make clear the significance of the happens, as I again emphasise, through the prenatal and perinatal period for the collective co-ordination in contact through the eyes, experience without by discussing the existing through mimic, gesture, movements and literature in detail, as I have done elsewhere mutual empathy. By means of “attunement”, (Janus 2000). In doing so, the anthropological that is, mutual fine co-ordination, something and psychological significance of the so-called of the primary union is restored. The intensity “physiological premature birth” is a somewhat of the relationship between mother and child

156 Prenatal period of life as a matrix for our lives and our societies therefore compensates for the biological In the co-ordination between mother deficiency of premature birth. and child, rhythmic movements, imitation This explains the existential intensity of of sounds, and emotional resonance play human relationships. This isn’t just a matter an important role. In rhythmic rocking, the of security but always the preservation of prenatal rocking by the mother’s movements integrity as well, the inner union that was is reproduced as is the connection with lost too early. Its loss means at the same time the prenatal acoustic world by the tones, an early achievement of integration, which speaking and singing of the mother. We can means balancing the mother’s complex world surmise that the roots of dancing, music and of experiences. Just as the child always has to speech lie in this configuration. The music balance itself with the mother’s movements theorist Parncutt says succinctly: “Music is before birth, it always has to balance itself with the prenatal mother” (Parncutt and Kessler the emotional fluctuations of the mother’s 2007). Through dancing, music and speech experiences. The consequence of this is a kind lifelong echoes of the prenatal union are of premature development of the ego, the ego reproduced together with others. This all being understood as a centrally regulating facilitates mutual emotional resonance as it authority. This is true of the prenatal period existed in the prenatal situation. and especially of the postnatal period. The ego of a primate baby, as far as it can be spoken of, is embedded in the adequate living situation The social processing of “physiological with the mother. The ego of a human infant premature birth” is challenged to always establish and maintain This magical union with the mother is its security and its inner integrity by means of transferred successively to the family, the a subtle co-ordination with the mother and group and the world at large. In human her psycho-cultural identity. A requirement relationships it is also always dealing with for this is exactly this particular intensity of the invocation of the the primary union. The the mother-child relationship. Freud already dual reference of the relationship world of discussed these interrelations presciently the infant is therefore preserved. We live at when he wrote: “The biological factor is the the level of instincts and needs of our primate drawn out helplessness and dependences heritage and simultaneously at the level of of the small human child. The intrauterine retaining the connection with the greater existence of humans appears in comparison whole, be it primarily the pre-birth mother, to most animals relatively short; they are sent then the infant’s mother, and later the family, into this world less completed than these. the social grouping and the world as a whole. In this way the influence of the real external In the tension between these two levels world is strengthened, the differentiation of lie the roots of the special developmental the ego is brought forward, and the dangers dynamism and creativity of humans. The of the external world are heightened in their matrix of prenatal and perinatal experiences significance and the value of the object which is projected onto the world as a result of alone can protect against these dangers and the “physiological premature birth” and by replace the lost intrauterine life is enormously this the real world is interpreted as a state increased. This biological moment poses the of “being at home” provided by a superior first danger situation and creates the need maternal being. Because the in reality still to be loved that will never leave humans” prenatal infant cannot bear the external world (Freud 1926, p. 168). Here the discovery of it accepts the after birth mother emotionally “physiological premature birth” has therefore at the same time as the pre-birth mother. been anticipated at the psychological level Thus an emotional horizon of senses is created by over 40 years. When however a real which has to be continually reconnected relationship can be described in the same with reality, an elementary challenge for the way at different methodological levels, here ego’s integrative ability, for intelligence and the psycho-biological by Freud and the creativity. One can even conjecture that the evolutionary-biological by Portmann, then it origins of the incredible growth of Homo speaks for its great significance and can be sapiens’ brain capacity lie in the need for held to be proof. this complex achievement of integration.

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Premature birth and brain development run mirror of prenatal primal experience also parallel in the evolution of mankind. as a sort of “being at home” which has been Human creativity is challenged to prepared for them by a higher being. Curiosity continually find new alignments between the about the external world is at the same time primal experiences formed in the prenatal curiosity about the projected internal world. and perinatal periods and the later worldly The external world appears as the external experiential horizons in harmonious forms. world and at the same time as a mysterious Humans are in this sense condemned to internal world in which everything is creativity or, put another way, creativity is a connected with everything else and with which primal root of human existence. In prenatal one is in a mysterious way associated. Rilke psychology these interrelations are discussed was perhaps referring to this relation when in different ways, see for example Rank (1924, he presciently spoke of the “world internal 1932), Renggli (2001), Evertz and Janus space” (“Weltinnenraum”). The prenatal (2002), Janus and Evertz (2008) and many microcosm is mirrored in the postnatal others. macrocosm and the postnatal mystical contact to the universe mirrors the mystical contact to The processing of early experience in the prenatal universe, as represented by the mythology mother to the child. This is the atmosphere A concrete example of mythological proces- of the magical dreamtime culture as depicted sing of early experience is said to be the tree: by the Australian aborigines and many the tree is in many ways important for the tribal cultures. The decisive point is that the primate being in us – we find shelter under horizons of interests and activities of humans it or in its branches, the leaves and fruit can in the world extend far further than the also be nourishing and so on; the tree is over limits of a primate. When the whole world is and above this important and “sacred“ as the experienced as the reflection of the maternal “perceived” return of the lost placenta or the primal “being at home“ then I also want to umbilical cord for the being of premature investigate it and get to know it just as the birth in us, that is searching for its too early child is studied and gauged. This increases lost “being at home”. The projection of the the room for basic consideration and reflexion prenatal experience of the placenta onto the about the narrow area of interest of normal tree or respectively the experiencing of it in primates. Through projection, world aspects, the mirror of the prenatal experience turns which are otherwise of no interest to primates, the “sacred” tree into a symbol of union. A become of interest to humans. Because, for central image in different mythologies is that example, the tree as a sacred tree appears the world will exist as long as the tree of life, emotionally so significantly and mysteriously such as the Nordic World Tree Yggdrasil, nourishing, it also becomes interesting in its lives. When the World Tree falls, the end reality. Its nature and its real potential are of the world will start, just as the breaking researched and so it is possible to develop it down of the placenta at the end of pregnancy into a fruit-yielding tree. This is an approach initiates the end of the prenatal world. In towards explaining the interest of humans in these connections lie important roots of nature studies, the extent of which separates symbol creation: the symbol of the snake has us so very much from other primates. a root in the experience of amniotic fluid, etc, Man wants to become closer to “God” by which is however another topic and will not be recognising His laws without realising that followed up here. “God” is a manifestation of the pre-birth mother. Sloterdijk (1999, p 549) speaks in this The relation of humans to the world as connection of the Uterodizee of the concept of prematurely born primates God. The projective experience that results from A particularly striking example of this is this premature birth and the particularities the human interest in the processes in the of early communication (confirmation of heavens which mirror the “uterus heaven” union) has fundamental consequences for the (Grössing 1994). The canopy of the heavens relationship to the world. Humans perceive is emotionally a return to the canopy of the the environment not only as such but in the uterus, which forms the amnion. Because the

158 Prenatal period of life as a matrix for our lives and our societies processes in the canopy of the uterus and the Another example for the further processing forces at work behind them are so mysterious of a projection of the uterine experience is and meaningful, the heavens and “the forces the enclosure of a settlement. To begin with, at work behind them” are of such interest. This drawing a circle round a certain area sufficed is why the movements of the stars appear so to give it magical properties. The circle turned fascinating and challenging to inquisitiveness this area into a “cosmos”, as the Aborigines and real observation and learning begin said. This gave it a feeling of being home. The and is continued over the generations. This circle had created a relationship to the origins. also receives a very practical meaning for This was its primary function. It was not until spatial orientation and for recording time. after this that it became clear that it might These practical results in their turn further be sensible to make this originally magical retroactively the interest in observing the protection concrete by erecting a real wall or stars and researching their movements, so fence. that finally the interest in researching nature Humans became willers and doers and technology detached itself from its through their technical capabilities. This is mystic background which is, however, still the start of ego formation. This is mirrored noticeable in the sense of elation and unity in the self description of the early pharaoh that accompanies the research and discovery Unas: “... Unas, the steer of the heavens, of the laws of the heavens. The fascination of impatience in his heart which lives from the the heavens is not only the starting point for essence of all the gods, ... because Unas is researching nature but also for psychology. the great power, the most almighty ... the The heavens become a field of projection for life time of Unas is all time, ... if he wants, personal emotionality. Mankind discovers he will do, if he does not want, he will not itself as it were in the mirror of its projections. do” (quoted from Clarus, 1980, p. 32). This Astrology thus becomes the first psychology, led over generations to the development of which we can also reflect today in all its ego capabilities and corresponding social splendours. Nowadays, this view of astrology structures and reinforcement of the ego. But could be described as follows: it is not the this ego was not able to experience itself as stars that determine our fate, but the feelings such. Finally the strength from the origins of our inner world that are projected onto the was what enabled it to act. This is why it constellations. The constellations themselves ascribed these capabilities to higher powers are already projections of inner archetypal or divine beings. Corresponding to the images which have their roots in the prenatal personal ego differentiation the otherworldly primal experience. powers acquired differentiation and personal Similar deductions can also be made features. The mirroring in the otherworldly for other fields of human interest, such as, figures in return strengthened the personal following a suggestion from Ranks, fire: one ego. Humans found and invented themselves aspect is fire’s warmth which in an adverse in the projection onto the otherworldly and cold world could be an emotional return to figures. This is the transition from the magical the prenatal warmth of the mother that keeps world of the tribal cultures with its extremely the child warm before birth. So seen, fire can impersonal and nature-bound demons to the become a sacred fire that is worshipped and mythical world of the early city cultures and whose presence ensures the relationship to civilisations which the psychologist Wundt the primary union with the prenatal warmth also described as the “age of heroes”. And and for this reason it becomes interesting they really were heroic deeds that the peoples and humans occupy themselves with it and of the era accomplished with the invention of learn to use it. In the process the practical agriculture and livestock holding, the building significance becomes more important and the of cities and the invention of writing. The mystical significance recedes, even though related grandiose strengthening of the ego in some advanced civilisations, such as that awareness was mirrored in the hero ego, the of Rome the sacred fire in the Vestal temple prenatal origins of which will be dealt with in was a central retainer of the state, ensured the the following passage. relation to the primary unity.

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Digression on the hero ego external world are entwined with the changes Human history is the history of increasingly and developments in the internal world of the complex structures in the technical mastery of ego. Just as we have created our cultural world the environment and the forming of society. in the course of time, so have we developed This corresponds to the complicated structure our modern ego with its capability of complex of our relationships, our inner world, our control. emotionality and particularly internal control The changes in the forming of the external and self recognition. This can be combined world, relative to the prevailing times, are in the concept of the ego as the centre of an extensively connected with our elementary experiencing, controlling, willing and acting real needs and at the same time with our instance. The individual formation of the ego prenatally determined wishes union. This is itself rooted in the distinctive features of the corresponds with, as previously said, an early interaction with the mother. The mother increase in the complexity and competence of not only restores the primary union with her the ego so that today we can feel ourselves to relationship but also the “foetal omnipotence” be the directors of our own self-responsible of the prenatal period, in which every desire lives. The mother imparts from the beginning is instantly gratified, with her admiration of the cultural patterns that define her within the child. Something of this is still noticeable her life. This is why the early formation of in Unas’ words. The infant’s weakness and the ego is always also defined and formed helplessness is compensated for by the through the cultural affiliation and identity of mother’s affirmation and admiration so that the mother. The child therefore learns from it doesn’t notice its real impotence. This the outset the cultural conditions of its time strengthening of the ego is later mirrored and possibly is able for this reason to grasp its projectively in the heroes of stories and cultural singularities in the learning process myths. This is really no personal strength, but so quickly and comprehensively in its youthful strength borrowed from the relationship to the development as to enable it to create its own mother. The mythical show is an action level new concepts in adulthood. Individual and of self-realisation. It is fed by the presence of collective developments therefore act together the prenatal and postnatal blended world of upon the formation of the ego. the first year of life where the child is already The following passage outlines the drama in the world and simultaneously still in an of the psycho-historical development of the imaginary womb world due to the mother’s ego in order to emphasis the significance of assistance. This blended world was staged these connections. in cultic celebrations and also in initiation ceremonies as ritual spectacles and this led The psychohistory of the ego’s to the awareness that it was also possible to development speak of it in mythical tales, as the Russian This process of the ego’s development took researcher of fables, Propp (1968) has place historically as an intergenerational illustrated: the substance of the initiation learning process covering many generations. ceremonies provided the material for later As I find it so important to regard the fables. These stories in turn make it possible historical processes basically as a process to recognise, or at least to surmise, that these of development of the ego and not only as myth-like happenings are a reflection of my a history of the doings of political rulers or own experiences, or I can discover myself in social changes, I would like to very sketchily the mirroring of the projection itself as we describe at least some stages of the historical can now understand fables psychologically. development of the ego. The cultural historian The projected feelings are found to be one’s Jean Gebser (1949) described in his work own feelings and conflicts. This development “Ursprung und Gegenwart” (“Origin and of ritual through myth and narration to Now”) basic forms of development of the ego psychological understanding is a process of and their corresponding weltanschauung. learning and emotional creation of self that He differentiates between a magical, a mys- has run through many, many generations, tical, a rational and an integral structure of each generation adding a new dimension. awareness or ego, whereby he uses integral The changes and developments in the cultural to try to describe our present day ability

160 Prenatal period of life as a matrix for our lives and our societies to reflect psychologically and integrate the Naturalism and Realism dealt concretely with earlier structures that still exist within us. people’s feelings and conflicts in their real In favourable circumstances such a col- life surroundings with which everyone could lective development of the ego can take place immediately identify. This is the expression of in a few generations, just as Greek drama a further growth of the ego. The Enlightenment developed over a short time in history from let everybody think for themselves. This made its origins in ritual satyr dances through itself physically felt in the masses of inventions the still myth-telling Aeschylus to the that were made by individuals who would already psychologically reflexive Euripides. never have dared to do it under the horizon A preliminary stage of this developmental of religious dependency. Here I only want to process had already taken place in the mention the invention of Braille writing for transition from the Iliad to the Odyssey: while the blind by Louis Braille. Blind people had the heroes of the Iliad are still fixed wholly in a always lived in exclusion from the culture of mythical horizon, Odysseus is a comparatively literature. This had always been accepted as consciously acting and feeling person. With fate and appeared to be willed by God. New Greek philosophy for the first time in history was the fact that an individual was moved by it was possible to construct a rational ego. their affliction to develop a form of writing for One fundamental reason for the blockage the blind. of further development in the classical Greek The progenitors of this development were and Roman societies appears to be the social the inventors of the Renaissance, such as structure of a society based on slavery which Leonardo da Vinci, for whom the invention of limited real individualisation, as was later technical gadgets and understanding actual possible in Western Europe. processes, such as bodily functions, was a real Because the ego’s possibilities in antiquity desire which would have been unimaginable were further nurtured by the history of the to the weaker ego of mediaeval humans. Germanic characterised successor states This new development had begun with of the Roman Empire, it was possible here the enjoyment of personal feelings as for the ego’s evolution to occur faster in the expressed by minne song. It was not uniform late Middle Ages than in Antiquity. The and started in different fields. In the field Nibelunglied already showed evolution in of religion the Reformation was just such a that it describes the characters with their stimulus of the personal development of the conflicts in a lengthy story line, in contrast ego consciousness and the withdrawal of to the mythical Norse sagas which tell of projections. This development was perfected supernatural adventures of divine characters only with the Enlightenment in that the in which the ego remains at a projective Godhead was assimilated by one’s own will, level. In the late Middle Ages a sense of ego as Schiller put it. Then a rapid development developed slowly as described by van Dülmen in the expansion of personal feelings began (2001) The drama of this development can be which in the 19th century above all applied to seen in the fact that in Renaissance portrait the erotic feelings between man and woman. painting depictions of God were superseded The emancipation of women, which was by the portraits of real people. In Dürer’s initiated in the Enlightenment, led to men self-portrait the portrait of the son of God being confronted with their fears as embodied shimmers through. by the femme fatale. Realism and Naturalism A further large step on the way to a more traced the afflictions of people that resulted complex structure of the ego is represented from their social background. by the dramas of Shakespeare. Whereas the The collapse of the bourgeois family actions of divine characters were shown lifestyle of the 19th century rendered the roots episodically in mediaeval mystery plays of familial life and experience in the prenatal without development of feelings, Shakespeare period accessible. These had been previously is concerned with the feelings and conflicts of been masked by the idealisation of the family. real people, admittedly of royal or aristocratic Kafka in particular formulated pre-verbal blood. feelings paradigmatically. This is also partly true of German In this way the depth stratum of the self Classicism. It was only in the 19th Century that experience became accessible which had up

161 Ludwig Janus to then been projected in the experience of The world as an imaginary home the earthly valley of misery. What Kafka only From experience gathered from patients in indirectly formulated in the medium of the psychotherapy we know that a differentiated relationship with the father was expressed by personal development is only possible through the next generation of writers of modernity, the medium and the intimacy of a very such as Beckett, directly as the childish misery personal relationship. We need the reflection of the missed mother. in another person to find ourselves as The history of the ego’s growth can be subjects. An ego development is then possible followed directly in authors: Thomas Mann in the mutual interaction of the relationship. describes directly the decline of idealisation, It has already been mentioned above that Franz Kafka records the consequences for the one result of “physiological premature birth” inner feelings, and Samuel Beckett clarifies is the great intensification of the mother- the connection with the missed relationship child relationship. Through the intensifying to the mother after birth (Janus 2001, p. 216). of the relationship the child anchors itself in The decline of the idealisation of the old the security provided by the affection of the style of family life corresponds to the decline mother. And as could be said in a rather old- of the idealisation of the monarchy, insofar fashioned way she replaces the love of the as the family of the king or emperor was so prenatal relationship that was lost too early, or to say the heavenly guarantor of the bourgeois restores the primal love at the postnatal level family. of life. This primal love is then transferred to The democratising of Central Europe the family, the social group, society and finally after the First World War and the associated to the world itself. It can also be so expressed: challenge for self-responsibility furthered the we experience the world on two levels, the coming to terms with the depths of one’s own level of the primate Homo sapiens, and the ego, which was formulated in psychoanalysis. level of a foetal child: the world is a very The knowledge of psychoanalysis and real one in which we live our primate lives the significance of the early parent-child and at the same time a prenatal imaginary relationship for the person’s development home. And this is not just a condition at the entered literature and especially the new magical or mythical stage but also applies in medium of the film. This was rather a topic the same way in the present with the proviso of the western democracies than the Central that we are now in a position to penetrate the European powers, which were still caught connections. Human culture has consisted in a deficient father orientation. It was not from the beginning of balancing these two until after the Second World War that this levels with each other. Here is the primal root knowledge gained access to wider social strata of creativity that characterises Homo sapiens in Central Europe as well. The prevailing and makes him so unique. In the course of personal ideal of the dominant male, as history we have so altered the world that it personified by the Kaiser and later by leaders satisfies both in reality and symbolically our at the ideal level, became obsolete through the foetal needs by providing us in our societies demise of this type of personality on the defeat with a relatively safe living space. Everybody of Germany and Italy in the Second World works with unbelievable intensity at this task War. Then the development of the ideal of the of reforming the real world into a primal home. democratic and feeling man also took place in The price for the creation of this imaginary Central Europe with the help of the Allies. world of security is the need for all to work for In the above I wanted to describe in outline all. In earlier civilisations this work still had the individual steps of the ego’s development mainly imaginary features in that it served also to illustrate that, despite this incredible to make a heavenly life possible on earth for increase in complexity and scope of the the god king, in which we could emotionally reflexive areas, externally as well as internally, participate. So that one individual can of the modern ego the projective base frame experience himself as a will-possessing ego, that the world is some kind of home remains all the others place themselves at his disposal in the end. It is only within this base frame like a good mother and are there permanently that development was possible. This will now for him and all his needs. In this projective be only briefly explained. mise-en-scène, the project is developed of an

162 Prenatal period of life as a matrix for our lives and our societies empowered ego on a further social level. The or culture-psychological meaning over historical process fundamentally consists then and above this. Thus it could contribute of an internalisation of this situation, in that to qualifying and bridging the present today everyone can be a willing ego and we all complete division between history and depth make this possible for each other through our psychology by supplying the developmental work. The psychological background for this psychological frame described above that is that we experience the world emotionally could make some of the idiosyncrasies of as an imaginary home that is modelled on Homo sapiens more understandable. This the prenatal home. And we are in the process also has quite practicable features insofar as of mutually fulfilling this dream because we some irrational seeming behaviour becomes need this for our emotional survival after the more understandable by reference to prenatal affliction caused by our too early birth. psychology at the collective level. We exploit the world in a rigorous and totalitarian manner as if it can go on endlessly providing for us, CLOSING REMARKS like a mother for her child before birth. At the postnatal level, however, we have to consider My thoughts on the anthropological and and take responsibility for the consequences psychological meaning of the prenatal period of our behaviour. Due to its “physiological of life and birth are basically intended to premature birth” Homo sapiens is, however, point out that prenatal psychology does always in danger of acting and experiencing in not just have special significance in the some kind of prenatal trance and so putting sense that it is important to investigate itself into danger. the importance of prenatal and perinatal Because of the importance of the experiences for life history in order to make connections given, it is a task of the future to dealing responsibly with the earliest mother- discuss these in a responsible manner and to child relationship possible, but also has a work out ways of further communication. further fundamental collective-psychological

references

1. Clarus J (1980). Du stirbst, damit Du lebst. Bonz, Fellbach. 2. DeMause L (1982). Foundations of Psychohistory. Creative Roots, New York. 3. Evertz K, Janus L (2002). Kunstanalyse. Mattes, Heidelberg. 4. Fabricius J (1989). Alchemy. The Aquarian Press, Wellingborough. 5. Freud S (1926). Hemmung, Symptom und Angst. Ges. Werke 14. Fischer, Frankfurt 1969. 6. Gebser J (1949). Ursprung und Gegenwart. Deutsche Verlagsanstalt, Stuttgart. 7. Gould S (1992). Human Babie as Embryos. In: Gorld S: Ever since Darwin. Norton, New York. 8. Grössing G (1994). Der Uterushimmel als Vor-Bild zur Naturforschung. Int J of Prenatal and Perinatal Psychology and Medicine 6: 315–335. 9. Janus L (2000). Die Psychoanalyse der Geburt und der vorgeburtlichen Lebenszeit. Psychosozial, Gießen. 10. Janus L (2001). The Enduring Effects of Prenatal Experience. Mattes, Heidelberg. 11. Janus L. Evertz K (2008). Kunst als kulturelles Bewusstsein vorgeburtlicher und geburtlicher Erfahrungen. Mattes, Heidelberg. 12. Morgan E (1995). The Descent of the Child. Oxford Univ. Press, New York, Oxford. 13. Parncutt R , Kessler A (2007). Musik als virtuelle Person. In Oberhoff B, Leikert S (ed.): Die Psyche im Spiegel der Musik. Psychosozial, Gießen. 14. Portmann A (1969). Fragmente zu einer Lehre vom Menschen. Schwabe, Basel. 15. Propp V (1968). The Morphology of the Folktale. Univ. of Texas Press, Austin TX.

163 Ludwig Janus

16. Rank O (1924). The Trauma of Birth. Warner Torch Books, New York 1929. 17. Rank O (1932). Art and Artist. Norton, New York. 18. Renggli F (2001). Der Ursprung der Angst.m Walter, Düsseldorf. 19. Ridgeway R, House S (2006). The Unborn Child. Karnac, London. 20. Schacter DL (1994). Memory Systems. MIT Press, Cambridge. 21. Sloterdijk P (1999). Sphären I. Suhrkamp, Frankfurt. 22. van Dülmen R (ed.) (2001). Die Entdeckung des Ich. Wiss. Buchgemeinschaft, Darmstadt.

 Contact: Ludwig Janus, Schröderstr. 85, 69120 Heidelberg, Germany E-mail: [email protected]; [email protected]

164 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 165–173

MORE THAN NEIGHBORS: A COMMON BASIS FOR RELATIONSHIP-CENTERED MEDICINE AND SCIENCE

Hans von Lüpke

Auf der Koernerwiese 6, D-60322 Frankfurt/M., Germany

Reprinted: Int J Prenat Perinat Psychol Medicine. 22(3–4): 205–216, 2010

Submitted: 2011-10-24 Published online: 2011-12-15

Abstract Causal linearity is still one of the fundaments in scientific thinking. It remains unquestioned in spite of the fact that scientific results in important fields of human life such as genetics and brain function obviously do not follow linearity. Instead, they follow non linear laws as conceptualized in the Chaos Theory, the concepts of complexity or the quantum theory. Because of the fact that the same dynamics can also be found in relational oriented dialogic communication, the traditional gap between natural sciences and humanities seems to vanish. It appears that there has not been made use of the resulting open space for creative interdisciplinary research REVIEW and practice in human sciences up until now. The reason is obviously a fear of losing stability. The final discussion in this paper deals with the consequences of rigidity and discrepancies in the conceptualization of pathology, rehabilitation and psychotherapy. The balance of the dialectic tension between the pole of security as a human need and the aspect of playful creativity seems to be fundamental for a relationship oriented medicine.

Key words: brain research; genetics; complex systems; quantum theory; humanities vs. natural sciences; dialogic communication; linear-causal relationship; non-linear dynamic systems; chaos theory

Beyond castor oil and bloodletting: It was the physician Andreas Vesalius triumph of the hard facts from Brussels who said that his greatest The beginning exploration of the laws of achievement was to „describe the complete nature during the renaissance also gave human body, whose anatomy no one the medicine a new foundation. Up until understood“ (Andreas Vesalius Google then, the ideas of the ancient gladiator- Personenlexikon 2009). His working physician Galen had been applied in conditions had little to do with those of human anatomy, with the blessing of a modern scientific laboratory at first. the church. Students receiving their He searched for bones in the cemeteries academic training stood in a gallery of Paris, where he did research on the watching a barber-surgeon cutting open corpses of hanged felons and had to “fight the corpses, meanwhile listening to the off the many wild dogs”. Even by the time professor reading from Galen’s works. No he was the personal physician of Emperor one cared for the fact that the scientific Charles V and his groundbreaking work of consensus, which for the most part human anatomy was gaining recognition, was based on the dissection of animals, there were still attacks such as the one often times did not correspond with the from a certain Jacobus Silvius: “I beg you actual proportions of the human body. not to listen to a certain ridiculous and

165 Hans von Lüpke insane person, who lacks all talent and who becoming a leading science even beyond the curses and insults his teachers in the most medical field. Humanities such as education, blasphemous ways” (Ibid.). The advancing psychology and psychotherapy increasingly orientation towards scientific explanatory subordinate themselves to it. According to models led to the increase in diagnostic brain-researcher Wolf Singer, “brain research and therapeutic possibilities in medicine is one of the big adventures of human curiosity, which still continues today. Castor oil and similar to cosmology and particle physics..., bloodletting were less often the method of though regarding its consequences for our choice. Psychic abnormalities were no longer idea of man, brain research is probably the seen as a sign of “moral depravity” but were most exciting of these scientific disciplines” (as attributed to pathological changes in the brain quoted in Görnitz and Görnitz 2006, p. 58). In and, instead of punishment, they were treated a “Manifest of eleven leading neuroscientists” with the respective current knowledge. it says that “In the foreseeable future, say Medical proof, supported by empirically the next 20 to 30 years, brain research will funded “hard facts” became more and more be able to explain the relationship between important. Diagnostic and therapeutic neuroelectric and neurochemical processes strategies led by experience and relationship- on the one hand and perceptual, cognitive, aspects were outsourced into separate fields mental and motor skills on the other hand to of study (such as “Psychosomatic medicine”) such an extent that predictions concerning or shifted towards “non-scientific alternative” the links in both directions will be possible cures. They increasingly disappeared from with a high degree of probability. This means conventional medicine. The newest attempt that the mind, consciousness, feelings, acts of to explain the individual characteristics of the will and freedom of action will consistently particular person with only scientific data can be regarded as natural processes, because be found in “individual medicine”. Professor they are based on biological processes Dr. Regine Kollek, technological impact (Das Manifest 2004, p. 36). A “biological assessment expert for modern biotechnology psychiatry” has already drawn the conclusions at the University of Hamburg and a member that classical psychiatric concepts of illness of the German Ethics Council, expects such as depression, psychosis etc have medicine to develop from an “empirical become obsolete and that these diseases are to medicine” into a “rational, molecular be defined as metabolic disorders in the brain science”. The individualization of medicine (Mayer 2002, quoted after Bauer 2003). will cause medical actions to become more and more dependent on scientific analysis The hard facts are melting and interpretational competence. In “Pro What characterizes all these concepts is the Gesundheit” from the self-help initiative fact that they are based on research that uses HFI e.V. Karl-Gustav Werner explains that new technical capabilities to advance into the physician’s role will differentiate itself smaller and smaller (molecular) dimensions. between “a continuous companion of the Molecular genetic data plays an important insurant for bio-psycho-social-medicine” and role in this. However, the foundations of the an “anonymous specialized care provider”. scientific fields used to achieve this increased Kollek says that the categories of health and precision are not being noticed and therefore sickness will change as well: “If health is the are not being discussed. This is especially result of will, sickness is the effect of a wrong relevant with regards to new developments in or missing will.” She understands the term genetics, where the idea of the role of genes “individualized” not as a self-interpretation has fundamentally changed. While it used to of the individual person and the individual be assumed that a linear-causal relationship doctor-patient relationship, but rather as existed between genetic information and a concept of illness based on the molecular its implementation, it is now known that processes of the genetic deposition of humans genetic information, in order to take effect, (World Health Summit: Personalisierte needs an environment-dependent activation Medizin 2009, p. C1733–1736). by a “gene expression” (Bauer 2002, Kandel On the basis of technically refined 2006). Furthermore, research in the field of methods, science-oriented brain research is epigenetics has shown that genes, if they are

166 More than neighbors: a common basis for relationship-centered medicine and science chemically encased – by methyl-groups for well as implicit procedural and associative example –, can be inaccessible for generations answering, learning and recognition and then become effective again because of performances were observed” (Zieger 2005, p. environmental factors (Bauer 2008). The 6). Studies of the American brain researcher notions of “Individualized medicine” are Freeman (1995) also question the linear- therefore based on scientifically outdated causal orientation towards definable functions genetic data. All subjective, relationship- of individual brain areas. Freeman acquainted oriented aspects remain to be excluded, even bunnies with smells and found specific brain though they belong to the environmental wave activities for each smell in a brain region factors that newest concepts suggest are that was activated during the processing involved in activating genetic information. The of these perceptions. When he offered the increasing accuracy at the level of technical animals a new smell, they reacted with a new measurability loses sight of crucial factors pattern as expected, but at the same time the and becomes inaccurate while attempting patterns for all the other smells had changed. to become more exact. The same can be This backlash of context on the structure is said for the previously mentioned biological also evident on the neurophysiologic level. Not psychiatry and the increasingly popular notion one particular cause leads linearly to an effect, that the marking of biochemical-processes in but a change in one point of a system leads the brain will lead to a better understanding to changes in the entire system. Therefore of psychiatric disorders. These are based on it can be assumed that complex cognitive- the explanatory model that organic factors emotional processes can lead to interactions are causal and that a process can only be within the whole brain. It seems that concepts understood when its organic factor is found. beyond a linear-causal relationship are Not least because of findings of brain research required. Thelen & Smith speak of “non- it has been proven that this relationship also linear dynamic systems”: “Although behavior applies in the reverse: That environmental and development appear structured, there experiences, which include interpersonal are no structures. Although behavior and psychological processes (such as in psycho- development appear rule-driven, there are no therapy), can cause structural changes in rules. There is complexity. There is a multiple, the brain, again through the activation of parallel, and continuously dynamic interplay genes. Even in the “manifest”, the biological, of perception and action, and a system that, scientifically explorable processes are seen by its thermodynamic nature, seeks certain as causal: Mental phenomena are “based” stable solutions. These solutions emerge from – as has been quoted above – “on biological relations, not from design. When the elements processes” (further discussions on this subject of such complex systems cooperate, they give in von Lüpke 2006). rise to behavior with a unitary character, and Now the findings of brain research itself thus to the illusion of structure” (Thelen and call into question the sole orientation towards Smith 1994, p. XIX). Cilliers (1998) describes organ structures. Zieger (2009) for example the elements of complex systems, where a quotes studies which found that cortex sufficient number of such elements are ina neurons and cortico-subcortical connections state of dynamic interaction. This interaction over the thalamus – the connections between doesn‘t need to take place on a physical level, the cerebral cortex and deeper brain sections it can also be a mere exchange of information. - are not linked during the fetal development The single elements are neutral, they hold no until the 22nd week. Ultrasound examinations information and have no specific meaning. on the other hand show that in the 12th week Cilliers uses the carbon-atom as an example, fetuses already have a sophisticated movement which is always the same, whether it is in repertoire. Studies with anencephalic children a table, in a tree or in a human being . The who were born without a cerebrum also show mutual influence remains unpredictable. Big a behavioral spectrum that can‘t be explained changes can have little effects, tiny marginal by the verifiable brain structures. The ability factors can have dramatic consequences. of tonic-empathic dialog with smiling, Cilliers compares this concept to the meaning “spontaneous reactive physical, mimic and of words in the language as well as to the vocal self-tractualisations and expressions as neurons of the brain: “Meaning is determined

167 Hans von Lüpke by the dynamic relationships between the on their own, and their neighborhood, their components of the system. In the same way, no togetherness, their sequence and what else node in a neural network has any significance can be heard is not a mere term, but is filled by itself – this is the central implication of to the rim with sensual performance; but the notion of distributed representation. even though despite it‘s connectedness all this Significance is derived from patterns of can be listened to individually, it can also be activity involving many units, patterns that listened to as a whole, because that in itself is result from a dynamic interaction between the melody, and when listened to there is not large numbers of weights” (Cilliers 1998, p. something new next to the tones, intervals and 46–47). Exchange through dialogue within time, but with them. The melody is not added the context of relationships is equivalent to as an extra, but as a second way of appearing, such a complex system. Milani Comparetti a special form of existence, under which the (1996) illustrates this in his graphic of an form of individual existence can barely be upward moving spiral which is open at the top. perceived” (Musil 1952, p. 1313). The crucial factor in this case is the difference The concept of non-linear complexity is between the ideas of both dialogue partners also important for science. Another complex in the proposal and counter proposal and model, the Chaos Theory, developed from therefore the unpredictability of the exchange. natural sciences after it became clear that Milani Comparetti sees this as the dimension linear-causal models were insufficient, for of creativity. However, the model also shows example in meteorology. Again it’s about the the limitations of graphic illustration. The reciprocal influence caused by unpredictable exchange in dialogue takes place not only interaction between the individual elements. consecutively, but also simultaneously This includes marginal factors whose through an infinite variety of signals. While influence can be more significant than the one partner is talking, the act of listening Gaussian distribution would predict it to be. performed by the other partner is already The metaphor of the butterfly, whose wing an active communicative process. His facial beat in Brazil causes a typhoon in Florida, expressions continuously send messages of has become popular. The development of acceptance, rejection or disinterest to the quantum physics also stems from the need speaker. These messages affect the speaker for increasing accuracy. Görnitz and Görnitz and influence his current statement, which wrote: “That quantum theory is more again in turn influences the listener. Such precise than classical physics – contrary to interactions cannot be described linear- a widespread prejudice –, becomes obvious causal anymore, they can only be described through the fact that it was first discovered at as elements of a complex system. The single a time when classical physics had become very elements, whether they are verbal or non- precise experimentally as well as theoretically. verbal, receive their meanings only through Furthermore the quantum theory disregards different contexts. aspects of reality as ‘unimportant’ less than Music concretizes dialogical structures the classical physics do, seeing that it also and raises them above the psychodynamic considers the relationship between objects. constellations of individuals. In this case Relationship between separate objects can the sequence in a temporally progressing lead to a new whole with all the consequences process is inseparable from the simultaneous associated with it. Because of that it allows coming together of different voices. better predictions than classical physics and Again, the meaning is given through the a fundamental understanding of nature” context: The theme of the fugue often times (Görnitz and Görnitz 2006, p. 162). The role becomes interesting only towards the end, a of the individual elements as information dissonance, which in the classical theory of carriers in a context of relationships is also harmony requires a resolution, can be used evident at the level of physical measurability: as an acoustic color in modern music. Musil The physical becomes the artifact of the explains the interaction of such elements experimental conditions. According to using the example of melody: “In this Einstein’s formula E=mc2, “even deeper in (melody, added by the author) the tones have the ‘inside of matter’ there is nothing physical their independence and can be recognized left. The matter dissipates into energy, i.e. into

168 More than neighbors: a common basis for relationship-centered medicine and science motion, but not ‘into motion of something’, facts” are softening increasingly, while the but ‘into motion by itself’” (p. 159). “Quantum aspect of relationship as a central element information becomes meaningful, when it becomes easier to grasp not only in the field of is able to effect or control something inside human sciences. Relationship is no longer the its living carrier” (Ibid. p. 175). The observer “icing on the cake” that is kindly added for the also becomes part of this process. He sake of humanity, instead it has become an establishes a relationship to the measuring equally essential factor in both medicine and process “and through this interaction, the education. The decomposition into smaller internal quantum structure of the quantum units often carried out in research has already object changes” (Ibid. p. 161). This results in affected the “vast wholes”. Görnitz and “vast quantum states, which encompasses Görnitz exemplify this with the search “for the psyche and soma and cannot be explained needle in the haystack”: “It is done classically as an interaction through electromagnetic by examining piece by piece. The quantum or chemical information transfer” (Ibid. p. search captures all at once, and then – though 179). “The quantum theory describes ‘vast only with probability – finds the right straw, wholes’ that extend across space and time. i.e. the needle” (Ibid. p. 173). This however is The creation of Einstein-Podolski-Rosen- no longer conceivable. paradoxes (EPR-paradoxes), i.e. of quantum states extended over many kilometers Questions remain that, when measured, change immediately Is this not another attempt to explain as a whole, already establishes itself human scientific phenomena using natural experimentally” (Ibid. p. 174). Such models scientific methods and therefore regard would be the methodological requirement them as “natural processes, because they are for brain research that comprehends the sort based on biological processes” – as stated of phenomena that Freeman describes. A in the “Manifest”? Aren’t relationship- notion of that can be found in the “Manifest”: medicine and education just searching for In reference to the role of quantum physics the “blessing of natural science” again? In the authors write: In the long term we will contrast to a biologically oriented medicine establish a “theory of the brain” accordingly, that solely relies on natural scientific data, and the language of this theory will probably this is about an epistemological level. This be a different one than that which is known epistemological level, although developed in a in neuroscience today” (Das Manifest 2004, multidisciplinary manner within the limits of p. 37). The reference of Görnitz and Görnitz the natural science physics, provides models to the scientific significance of focusing with which humanistic phenomena cannot on relationships in terms of accuracy is of be explained but can only be described more particular interest here. Using the example accurately. Complex structures should no of therapeutic relationships they say: longer be reduced to simple ones – albeit at “Psychoanalysis can‘t help but to consider the price that these models aren’t conceivable the patient in his relationships, which anymore. makes it more concrete and therefore more Given this abstraction, the question arises accurate than a science, which simply tries to to what extent linear relationship structures understand the patient as an isolated object” such as the still conceivable causal ones (Ibid. p. 178). are actually dispensable. Don’t a number The consequence of the depictions up until of scientific research approaches and their now is that the affiliation between relationship- technical applicability continue to rely on this oriented medicine and scientific models goes relationship structure? Starting with infancy, beyond mere neighborhood. Contrary to doesn‘t orientation develop from causal widespread notions the humanities, which relationships? The baby already learns to are often classified as speculative, soft, associate steps, to understand the clatter in the metapsychological and inaccurate, are often kitchen as preparation for a meal, to associate times more precise than the sole focus on the rattle of the keys with the return of one of “hard facts” of evidence-based, linear-causal the parents. “Why-questions” are key issues research approaches. Especially the advancing during infancy and continue over the course of accuracy in physics has shown that the “hard a lifetime in different variants. Causality could

169 Hans von Lüpke be described in complex structures as well, as models, may give the impression as though an element of limited validity – An “attractor” this is an abstract theoretical discussion in the sense of the chaos theory. “Hard facts” without applicability. As mentioned, Görnitz are replaced by probabilities. The examples of and Görnitz discuss their view of quantum childhood development also make clear that physics in the context of more accuracy in the orientation towards causal relationships is psychoanalysis. Explicitly referring to Thelen inseparably tied to relationship experiences. and Smith and the papers of Freeman, the In the given examples, only the experience “Boston Change Process Study Group” of a coherent mutual relationship allows the (which includes Daniel Stern) discussed experience of reliable causal structures. Again consequences of unpredictability in the we are talking about information that receives psychotherapeutic process as an expression its meaning through context: every sound, of non-linear structures. In a paper of 2004 every word, a glance or a touch now attain the word “sloppiness” plays an important a meaning that is negotiated in a dialogic role. The authors speak of inter-subjective reciprocity. systems, which they characterize with terms such as uncertainty, surprise, confusion, Does the subject become arbitrary? improvisation, variation and redundancy. What becomes of the subject in the “vast “Although the sloppiness of the exchange of wholes” and a “determinacy of possibilities meaning introduces substantial uncertainty combined with an indeterminacy of facts” into the interaction, creating what usually are (Görnitz and Görnitz, p. 163–164)? Is it viewed as errors or mishaps, it paradoxically left up to randomness, an infinite number introduces new possibilities for increasing of “attractors” whose orientation remains the coherence of the interactive process unknown and can‘t be influenced? “Although between analyst and patient. Sloppiness is behavior and development appear rule- potentially creative” (Boston Change Process driven, there are no rules”: This sentence Study Group 2004, p. 695). Beebe et al. from Thelen and Smith (1994), already quoted (2000) – also against the backdrop of Thelen above, now becomes relevant again. The and Smith’s concepts concerning non-linear subject is also made up of individual elements dynamic systems – studied the language which for themselves are neutral and which coordination between adults and infants at only receive meaning through context. In the age of four months and compared these physics, the observer decides through his results to the attachment behavior of the method of research whether to perceive children at the age of twelve months. They energy or mass – he changes the context by found that a very close coordination as well becoming part of it. In the development of as an extremely loose coordination were both a human being, relationships decide upon associated with insecure attachment behavior, which given possibilities can unfold. We will while a somewhat loose coordination never know what chances were left unused. showed a secure attachment. The authors The inherent self, seemingly being pushed called the importance of rhythm “one of the forward by rules, as described by Thelen and fundamental organization principles of social Smith, the recurrent theme of identity can communication” (Beebe et al. 2000, p. 77). only be detected dialectically: “Through the Disturbances, irregularities, “perturbations” thou a person becomes I” (Buber 1979). Only are believed to promote development and the other creates the conditions for identity, attachment, since they keep the system in shown graphically in the dialog spiral of motion. “In order for a pattern to be changed, Milani Comparetti. In one’s life – beginning a part of the system must disturb the – up with the fusion of egg and sperm cells – until that point – stable pattern” (Ibid. p. 73). there is no development stage beyond this In a very close-knit coordination the system dialectical polarization. can not change itself in order to explore new solutions. Overly stable patterns can only be Practical consequences torn apart. Rigidity becomes a definition of Dialectically cryptic formulations, as well pathology to the authors. Beebe et al. also as pointing out that “vast wholes” are only apply the consequences of these studies to comprehensible using quantum mathematical the psychotherapeutic process. Contrary to

170 More than neighbors: a common basis for relationship-centered medicine and science the optimal satisfaction of the child’s needs, it the risk of calling the own results into which in German literature – based on question and realizing that defining parts of Ainsworth’s concept – is a requirement for ones lifework are wrong. It is possible that the development of secure attachment (Brisch experiences from the past continue to have 2000), the development promoting role of an effect in the present, for example the futile “disrupt and repair” has been discussed in polemics of Jacobus Sylvius against Vesalius American infant research for a long time. Reck or, in the 19th century, the desperate uprise of et al. (2001), within the context of mother- the 73 year old hygienist Max von Pettenkoffer child-interaction during postnatal depression, against Robert Koch‘s claim that cholera was refer to studies in which the crucial factor for triggered by living pathogens. In front of the quality of the interaction is not seen in witnesses he swallowed a cholera bacteria the extent of agreement between mother and culture which Robert Koch had produced in child in their emotional expression, but the Egypt and said: “Even if I was wrong and the ability of the interacting partners concerning attempt would put my life in danger, I would “interactive repair”, i.e. to flexibly move back still calmly look death in the eye, it would not and forth between matched and mismatched be a reckless or cowardly suicide; I would die states. If a pair has reached a mismatched in the service of science, like a soldier in the state, it ideally moves back into a matched field of honor.” Thanks to his immunity, the state within two seconds. So once again, it is consequence of an earlier cholera infection, he not about structure, but – in accordance with survived. He did however carry out the suicide the dynamics of complex systems – about the nine years later with a pistol (Wunderlich variability within a system. Compared to the 2009). Today’s academic activities have more healthy control group, a “friendly responding in common with the interaction between an to each other” is described for the depressed infant and a depressive mother. adult interaction partners. The authors Postmodernism could be considered interpret this as a possible sign of conflict a further line of development. Lyotard prevention and restricted authenticity. A recommends (as portrayed by Cilliers high conformance in the interaction behavior 1998) to give up the idea of consensus, as it between depressed partners is seen as an leads to impoverishment. His idea was for indication for relationship problems and a knowledge to be continued in discourse, pathological communication structure. without trying to find a permanent grid. Rather than excluding all that does not fit Where is the controversy? into a pattern, he considered it a matter of All these concepts and experiences, however, finding meaningful relationships between are hardly noticed by the broad “scientific different discourses. Cilliers considers this community”. This becomes obvious with the “an inevitable feature of a complex, self- example of quantum theory. Even though organizing network” (Ibid. p. 118). However, Einstein‘s relativity theory is part of the general he also speaks of the danger of overloading the education now, the advancement of physics it network, which then “will show ‘pathological’ has triggered has been of little consequence behavior, either in terms of chaotic behavior for the academic activities. The complexity or in terms of catatonic shutdown” (Ibid. of the associated mathematical operations p. 119). Currently the trend is more towards should not be the only and may not be the catatonia. It is possible that “pure dissent”, crucial reason. The desire for “hard facts”: similar to continuous dissonance in music, A medicine which defines precise organic leads to stupor and arbitrariness. Perhaps findings as cause of disorders corresponds to this is about the preservation of a dialectical a deep human need for security and support. tension between harmony and dissonance, Behavioral problems also bring along the security and anxiety, reliable support and problem of guilt. In science, this leads to a risky adventure – which is similar to the tendency to delve even more into the details subject of identity. Cilliers postulation for a of limited fields of study – accepting the postmodern ethic within complex structures risk that in the meantime the foundations of can only become effective in this tension: these fields of study might lose their validity. “Respecting otherness and differences as The open conflict traditionally carries with values in themselves” (Ibid. p. 139). This leads

171 Hans von Lüpke us back to the aspect of creativity in Milani predictability. When patients complain about Comparetti’s dialog model. Can we affect the lack of love in their marriage, one can show the balance in this tension? Certainly not by them how precious this deadness is to them, propagating adventures. This would destroy how carefully they preserve it and how much the dynamic in the core. The well-designed they insist upon it – how the mechanization and from an educational point of view and the complete predictability of the act carefully constructed adventure-playground of love serve as a protective shield against prevents all the risky and forbidden adventure surprise and unpredictability. Therefore, that used to be possible on the abandoned ‘the secure attachment’ is not a particularly property. Kids “are irresistibly attracted to useful model for the romantic love between waste ... in waste products they recognize adults, except in regard to the dimensions the face which the material world turns of the imagination; the illusionary as well towards them, and only them” (Benjamin the security procuring. Love is not secure 1977, p. 22). Suddenly, we are transported by nature, but we are constantly trying to back to Vesalius’ work place, where he had to make it secure” (Mitchell 2002, p. 47–48). “fight off the many wild dogs”. The dividing What Mitchell says here about love applies line is not between natural science and analogously to any form of development, humanities, but is marked by the dialectical development-rehabilitation and therapy. In tension between the desire for safety and the fear of surprise and unpredictability we also curiosity for the unpredictable. If one wants search for security within the deadness and to be of influence, the confirmation of the predictability of learned techniques. The wish for security seems advisable, since it dimension of imagination, the playful, is the appears to be tabooed and frowned upon. The antithesis. It is therefore necessary to mourn psychoanalyst Steve Mitchell describes this in the loss of hope for “specifically directed” the development of romantic relationships: encouragement in order to make room for “The need for the feeling of knowing both creative leeway. his/herself as well as another person, the In this tension, “we can hope to keep in need for a completely secure attachment touch with our primitive selves whence the is important for children and adults. But most intense feelings and even fearfully acute certainty and predictability are difficult to sensations derive, and we are poor indeed if achieve in human relations. We constantly try we are only sane” (Winnicott 1978, p. 150). to reach an illusionary sense of duration and

REFERENCES

1. Andreas Vesalius Personenlexikon Google (2009). http://www.personenlexikon.net/d/andreas- vesalius/andreas-vesalius.htm. 2. Bauer J (2002). Das Gedächtnis des Körpers. Frankfurt/M.: Eichborn. 3. Bauer J (2003). Verbindungslinien zwischen Psychotherapie und Neurobiologie. Bvvp-magazin 3: 16–17. 4. Bauer J (2008). Das Kooperative Gen. Hamburg: Hoffmann und Kampe. 5. Beebe B, Jaffe J, Lachmann FM, Feldstein S, Crown C, Jasnow M (2000). System Models in Development and Psychoanalysis. The case of vocal rhythm coordination and attachment. Infant Mental Health Journal 21(1–2): 99–122. 6. Benjamin W (1977). Einbahnstraße. Frankfurt/M.: Suhrkamp. 7. Brisch KH (2002). Bindungsstörungen. Stuttgart: Klett-Cotta. 8. Buber M (1979). Ich und Du. In: Das dialogische Prinzip. Heidelberg: Lambert Schneider. 9. Boston Change Process Study Group (2004). The “something more” than interpretation revisted: sloppiness and co-creativity in the psychoanalytic encounter. JAPA 53(3): 693–729.

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10. Cilliers P (1998). Complexity and Postmodernism. Understanding Complex Systems. London/New York: Routledge. 11. Das Manifest (2004). Elf führende Neurowissenschaftler über Gegenwart und Zukunft der Hirnforschung: Elger CE, Friederici AD, Koch C, Luhmann H, von der Malsburg C, Menzel R, Monyer H, Rösler F, Roth G, Scheich H, Singer W. Gehirn & Geist 6: 30–37. 12. Freeman W (1995). Societies of Brains. A Study in the Neuroscience of Love and Hate. New Jersey: Hillsdale. 13. Görnitz B, Görnitz T (2006). Was kann die Quantenphysik zum Verstehen des Selbst beitragen? Self Psychology. 7, 24(2): 156–183. 14. Kandel E (2006). In Search of Memory: The Emergence of a New Science of Mind. New York: W. W. Norton. 15. Milani Comparetti A (1996). Von der Behandlung der Krankheit zur Sorge um Gesundheit. Entwicklungsförderung im Dialog. In Janssen E, von Lüpke H (ed..): Tagungsdokumentation. Frankfurt/M. (Internet: BIDOK). 16. Mitchell SA (2002). Can Love Last? New York: W.W. Norton. 17. Musil R (1952). Der Mann ohne Eigenschaften. Hamburg: Rowohlt. 18. Reck C, Backenstraß M, Möhler E, Hunt A, Resch F, Mundt C (2001). Mutter-Kind-Interaktion und postpartale Depression. Psychotherapie 6, 6(6): 171–185. 19. Thelen E, Smith L (1994). A Dynamic Systems Approach to the Development of cognition and Action. Cambridge Massachusetts: The MIT Press. 20. von Lüpke H (2006). Sprachliche Verwirrspiele – nicht nur in der Hirnforschung. Konsequenzen für Theorie und Praxis der Rehabilitation. Sonderpädagogische Förderung 51, 3: 229–241. 21. Winnicott DW (1978). Primitive Emotional Development. In: Through Paediatrics to Psycho-Analysis. London: The Hogarth Press, p. 145–156. 22. World Health Summit: Personalisierte Medizin (2009). Deutsches Ärzteblatt 106, 42, 16: C 1733–C 1738. 23. Wunderlich D (2009). http://www.dieterwunderlich.de/Max_Pettenkofer.htm. 24. Zieger A (2005). Wieviel Gehirn braucht der Mensch? Anmerkungen zum Anencephalie-Problem aus beziehungsmedizinischer Sicht. Überarbeitete Fassung eines Vortrags beim Interdisziplinären Fachgespräch „Kinder mit Anencephalie und ihre Angehörigen“; 26.–27. November 2004, Erfurt. 25. Zieger A (2009). Anencephalie als menschenmögliche Seinsweise – Neue Forschungsergebnisse und Konsequenzen aus beziehungsmedizinischer Sicht. In Goll H, Jaquier M, Römelt J (ed.): Kinder mit Anencephalie und ihre Familien. Bad Heilbrunn: Klinkhardt, p. 75–100.

 Contact: Hans von Lüpke, Auf der Koernerwiese 6, D-60322 Frankfurt/M., Germany E-mail: [email protected]

173 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 174–189

CURRENT PROBLEMS OF THE CZECH STATE- CONTRIBUTORY SUPPLEMENTARY PENSION INSURANCE

Jan Molek1, Martin Šimák1, Petra Molková2

1University of South Bohemia, Faculty of Health and Social Studies, Department of Legal Branches, Management and Economy, České Budějovice, Czech Republic 2University of South Bohemia, Faculty of Economy, České Budějovice, Czech Republic

Submitted: 2010-08-04 Accepted: 2011-09-23 Published online: 2010-12-15

Abstract State-contributory supplementary pension insurance is a popular product in the Czech Republic. According to the Association of Pension Funds of the Czech Republic, as of 31 December 2010 the pension funds kept files of approximately 4.54 million participants, with savings amounting some 216,109 billion crowns. In the long run, the pension funds show stabilized financial results (however, in return for low revenue). Although the pension funds have always reached positive or at least zero appreciation of clients’ savings (as it was required by law), once you have included the inflation rate, the situation becomes very different. Regulatory restrictions on the side of the state, along with high costs on the side of the pension funds are the main reasons why the revenue allotted to the participants more or less only oscillates around the inflation rate. The state-contributory supplementary pension insurance in its current form does not fulfil its primary function. Moreover, without significant support provided by the state the scheme is not even capable of competing with life-cycle mutual funds or other substitutes offered on the financial market. If, for the future, the supplementary pension insurance is intended to be a part (to be one of the pillars) of the pension scheme, fundamental

REVIEW reform is needed. Therefore, besides the analysis of the status quo, this article deals with a framework determination of necessary reform measures as well.

Key words: pension; retirement; pension fund; supplementary pension insurance; private pension scheme; participant’s contribution; state contribution

INTRODUCTION system (Krebs et al. 2007). It is based on private voluntary insurance, whose The amount of the retirement pension aim is to separate the redistribution in the Czech Republic is considered to function and the saving function. be adequate by 23% of the citizens. On It is based mainly on the following the other hand, according to 77% of the principles and starting points: respondents, the amount of the retirement • voluntary contractual insurance for pension for elderly people is inadequate, individuals; while 45% out of these respondents • separation from the state (i.e. consider the retirement pensions to be separation of the funding through “totally” inadequate. the state budget or para-fiscal social The voluntary private pillar forms an security fund within the budget additional segment in the social security system);

174 Current problems of the czech state-contributory supplementary pension insurance

• dissolution of inter-generation redistri- supplementary pension insurance follows bution; special rules. • generating insurance-technical reserves in The state-contributory supplementary insurance companies; pension insurance was introduced in the • use of the concept of equivalence between Czech Republic by Act No. 42/1994 Coll., payments from the insured and the the State-Contributory Supplementary allowances to be paid out in the future. Pension Insurance Act on state-contributory supplementary pension insurance and certain A typical feature of a voluntary private acts related to its introduction, as amended. pillar is keeping to the principle of According to the above-specified act,state- equivalence and using an allowance contributory supplementary pen- derived from earnings. Another characte- sion insurance means the collection of ristic feature is state support, usually in the financial contributions from participants form of tax benefits (Tröster et al. 2010). in supplementary pension insurance (and In the Czech Republic, state-contri- from the state as provided for the benefit butory supplementary pension insu- of the participants), management of such rance was introduced within the voluntary financial contributions, and the payout of private pillar (as a supplementary pension supplementary pension insurance benefits. scheme). Supplementary pension insurance cannot be Its aim was to help people when they carried on by any entities other than pension retire – it was planned that a certain amount of funds. A natural person may become a money would be added to their state pension participant if he is over 18 years of age and has every month. However, it does not work permanent residence in the Czech Republic. this way at all. As soon as the saving period The supplementary pension insurance policy expires, an overwhelming majority of the must be concluded in writing with a pension participants collect the lump-sum settlement, fund. while regular pensions are rather rare. The state contribution and the tax benefits are The act on supplementary pension really helpful as the product is used by over insurance defines two types of pension plans: 4.54 million active participants, but the • defined-contribution pension plan; average amount of savings per participant is a • defined-benefit pension plan. mere 47,600 CZK. The average monthly contribution paid by The pension plan is conceived as a defined- a participant (net of the state support) does not contribution pension plan if the size of the even reach 500 CZK despite the great support pension benefits is dependent on the sum of given to the companies – employers – who the contributions remitted in the participant’s contribute for their employees participating favour, on the participant’s share of the in supplementary pension insurance. pension fund’s revenues, and on the age from It is obvious that the direct support which the pension benefits are to be provided. provided by the state to this product In the case of the defined-benefit pension does not seem to be money that is being plan, the pension amount is determined ahead spent functionally. of time and is not dependent on the sum of the contributions remitted (the pension fund guarantees an agreed amount if the conditions The characteristics of state- for entitlement to such pension are met). contributory supplementary pension The act on supplementary pension insurance insurance determines the scope of the State-contributory supplementary pension benefits from the supplementary pen- insurance is, in a way, a specific Czech par- sion insurance which can be provided ticularity. It has features of life insurance to participants in supplementary pension but it is not life insurance. It looks like insurance, as well as the general conditions regular investing but the pension funds are of entitlement to these benefits (the specific not allowed to follow the rules of regular conditions are included in the pension investing. In short, the state-contributory scheme).

175 Jan Molek, Martin Šimák, Petra Molková

There are three types of allowances paid scope of pensions cannot be further extended from the supplementary pension insurance: by the pension fund): – old-age pension; • Lump-sum settlement – early-retirement pension; The allowance which shall be paid to the – disability pension; participant in supplementary pension –survivors’ pension. insurance instead of a pension. It is the total of the sum saved by a participant (which A participant in supplementary pension consists of the contributions paid in by the insurance is obliged to pay contributions participant and by his employer, of relevant to the supplementary pension insurance state contributions, and of the share of the pension fund. The size of a participant’s pension fund’s revenues corresponding to contribution must not be lower than the the amount of the contributions from the amount establishing entitlement to a state participant and the employer). contribution. A third party (usually the employer) may remit contributions, or a • Termination settlement portion thereof, on behalf of a participant. The allowance which shall be paid to the participant in supplementary pension State support insurance or to the natural persons appointed The state contribution in the Czech in the policy. The amount of the termination complementary pension insurance re- settlement consists of the total of the sum presents an unusual instrument as in saved by a participant (again, it comprises economically developed countries the state the contributions paid in by the participant support normally means a deduction of the and by his employer) and of the share of the remitted insurance amount from the income pension fund’s revenues corresponding to this tax base. amount. Neither the state contribution sums The state contribution is credited to a nor the pension fund’s revenues from the state participant’s account maintained by the contributions are paid out to the participant pension fund and is included in the base within the termination settlement. (capital) which is used for determination of the size of the allowance. The state contribution • Pension is provided proportionally – it is dependent A regular payment of a financial amount for on the size of a participant’s monthly a period determined by the pension plan contribution. The currently valid amount of (usually a lifetime payment). By law, the the state contribution provided to the private following types of pensions may be provided pension scheme is shown in Table 1. from supplementary pension insurance (the

Table 1. Amount of the state contribution

Monthly participant’s contribution (in CZK) Monthly state contribution (in CZK) 100–200 50 + 40% of the amount over 100 200–299 90 + 30% of the amount over 200 300–399 120 + 20% of the amount over 300 400–499 140 + 10% of the amount over 400 500 and more 150 Source: Act No. 42/1994 Coll.

It is planned in the amendment to the act the monthly participant’s contribution is at on supplementary pension insurance that least 300 CZK, and the participants whose the amount of the state contribution will monthly contribution is 1,000 CZK or more be altered from 1 January 2013 so that the will receive a contribution amounting 230 state will contribute to a participant only if CZK from the state.

176 Current problems of the czech state-contributory supplementary pension insurance

Another significant support provided to • are exempted from contributions to the supplementary pension insurance by the social security system and health insurance state (in addition to the state contribution) system; is tax relief – both for employees and for • can be claimed as the employer’s costs, employers. on condition that the contributions are mentioned in the collective agreement or the internal regulation (Sec. 24 (2) (j), Taxation clause 5 of the Act on income tax). The latest factual changes in terms of taxation of the supplementary pension insurance are Payments over the limit: included in the amendment to the act on • are not exempted from the employee’s income tax, implemented by Act No. 261/2007 income tax; Coll., from 1 January 2008. • are not exempted from contributions to the social security system and health insurance system; Tax relief for participants in supplementary • can be claimed as the employer’s costs pension insurance in any amount, on condition that the Participants in supplementary pension contributions are mentioned in the insurance are allowed to lower their income collective agreement or the internal tax base by a sum of contributions remitted regulation. during the taxable period as supplementary pension insurance, reduced by 6,000 CZK (pursuant to Sec. 15 (5) of Act No. 586/1992 Tax applied to allowances from the Coll., on Income Tax, as amended, up to supplementary pension insurance 12,000 CZK may be deduced from the income The tax applicable to allowances from tax base). supplementary pension insurance is deter- The tax deduction of the contributions mined in Sec. 36 (2) (n) and (s) and Sec. to the supplementary pension insurance can (8) (6) of the Act on income tax. Neither be claimed either by means of a participant’s the state contribution nor the participant’s tax return or through his employer within the contribution is subject to tax liability (but annual accounting of tax advance payments. the revenues from the contributions and the The eligibility for the deduction must be employer’s contributions are subject to tax demonstrated by: liability). Beginning from the taxable period • acknowledgement of the amount of 2008, a unified tax rate amounting to 15% was remitted contributions by the pension introduced: fund; • in the case of the lump-sum settlement, • supplementary pension insurance policy. the tax on revenue from contributions and the tax on employer’s contributions is 15%; Taxation in terms of employer’s • in the case of the termination settlement, contributions to employees (participants in the tax on revenue from contributions and supplementary pension insurance) the tax on employer’s contributions is 15% By amendment of the act on income tax, (neither the state contribution nor the beginning from the year 2008, a common revenue from the state contribution is paid ceiling for exemption from tax on income to the participant); in employer’s payments to supplementary • in the case of pensions, the tax on revenue pension insurance and life insurance was from contributions is 15% and the tax on introduced, amounting to 24,000 CZK (Sec. 6 employer’s contribution is equal to zero. (9) ( p) of the Act on income tax).

Payments up to the above-mentioned limit: Data about the state-contributory • are exempted from employee’s income supplementary pension insurance tax (provided that the employee is a There are a total of 10 active pension funds participant in supplementary pension in the Czech Republic (the number of the insurance); pension funds has decreased from originally

177 Jan Molek, Martin Šimák, Petra Molková

44 to the now active 10 pension funds, while the positions on the market offering services in the key positions in nearly all of them are held the field of supplementary pension insurance by foreign stockholders with strong capital). are shown in Tables 2 through 4. Their general economic characteristics and

Table 2a. Selected indicators related to pension funds as to 31 December 2010

Funds registered in favour of participants (mil. CZK) Number Registered Reserve Total Pension fund of partici- Participants’ State capital fund assets pants contributions contributions (mil. CZK) (mil. CZK) (mil. CZK) including including revenues revenues AEGON PF 116,444 3,125 607 50.0 20.100 4,233.40 Allianz PF 156,211 7,970 1,426 60.0 91.571 10,556.76 AXA PF 456,348 28,544 4,341 398.5 493.000 36,279.00 ČSOB PF 308,873 7,833 1,438 320.0 34.000 10,134.00 Progres ČSOB PF 431,741 15,009 2,754 297.0 151.000 19,346.00 Stabilita Generali PF 55,499 2,264 369 50.0 21.000 2,854.00 ING PF 429,126 20,550 3,361 50.0 170.000 25,492.00 PF České 1,179,881 44,203 7,922 214.0 323.000 55,305.00 pojišťovny PF České 907,803 29,854 5,319 350.0 194.000 37,624.00 spořitelny PF Komerční 501,199 24,407 3,977 200.0 250.000 30,602.00 banky

Source: Association of Pension Funds of the Czech Republic 2010 – publications issued by the pension funds

Table 2b. Selected indicators related to pension funds as to 31 December 2010

Pension Profit (loss) for accounting period after Participants’ finance (in thousands of CZK) fund taxation (in thousands of CZK) 2007 2008 2009 2010 2007 2008 2009 2010 AEGON –18,449 –50,282 –35,818 52,568 45,057 597,489 2,186,250 3,731,665 PF Allianz PF 201,200 220,181 251,099 309,752 6,073,898 6,706,299 8,015,142 9,538,982 AXA PF 790,438 9,682 790,469 565,630 32,228,016 33,840,522 33,138,995 33,245,247 ČSOB PF 121,031 –1,339 84,369 100,256 5,466,257 6,950,335 8,128,251 9,270,520 Progres ČSOB PF 338,713 7,988 258,572 286,427 14,223,520 15,783,721 16,704,947 17,762,848 Stabilita Generali 52,172 34,396 52,015 57,567 1,275,274 1,640,051 2,119,323 2,632,701 PF ING PF 509,642 8,767 21,255 518,418 18,857,648 21,617,431 22,808,906 23,910,458 PF České 938,616 81,354 619,012 1,147,390 37,182,519 44,154,556 47,812,388 52,124,745 pojišťovny PF České 775,563 127,447 458,531 807,354 24,424,229 29,672,440 32,513,101 35,173,368 spořitelny PF Komerční 562,256 165,158 74,606 726,815 22,667,727 25,735,997 27,178,729 28,718,275 banky Source: Association of Pension Funds of the Czech Republic 2010 – publications issued by the pension funds

178 Current problems of the czech state-contributory supplementary pension insurance

The number of the participants in 3.37%. Thus the supplementary pension supplementary pension insurance towards insurance is still developing, although the the end of the year 2010 was 4.543 million, trend is decreasing (see the following Table 3 which means an inter-annual increase by and Table 4).

Table 3. Total numbers of valid pension insurance policies during the period 2000–2010 (mil. pieces)

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Number 2.372 2.534 2.622 2.740 2.964 3.280 3.594 3.936 4.207 4.395 4.543

Source: Association of Pension Funds of the Czech Republic 2010

Table 4. Numbers of pension insurance policies (thousand pieces) and inter-annual development (%) during the period of 2000–2010

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Number 595 408 347 372 436 544 559 586 590 525 495 Increase (+) – –31.4 –14.9 7.2 17.2 24.8 2.8 4.8 0.7 –11.0 –5.7 Decrease (–)

Source: Association of Pension Funds of the Czech Republic 2010

The reasons why during the two last terms of the reforms to be implemented years the interest in supplementary pension in the pension system, as well as very low insurance is attenuating – which is indicated appreciation of the savings in the pension by the decreasing number of new contracts funds during recent years (mainly in 2008). (although the results are still satisfactory, in Another obvious factor is the saturated comparison with the previous years) – could market. be, along with the stagnating economy, the relatively high unemployment rate and the In addition, companies that often slowly growing wages/salaries, and also contribute to their employees have slackened the not very clear government strategy in their efforts (see Table 5).

Table 5. Numbers of supplementary pension insurance policies with registered employer’s contributions (thousand pieces) and inter-annual development (%) during the period of 2000–2010

Year 2000 2001 2002 2003 2004 2005 Number 416.57 567.75 650.21 779.99 801.63 927.93 Increase – 36.3 14.5 12.0 10.1 15.8

Year 2006 2007 2008 2009 2010 Number 1,028.85 1,129.62 1,222.64 1,261.52 1,284.74 Increase 10.9 9.8 8.2 3.2 1.8

Source: Ministry of Finance CR 2005

179 Jan Molek, Martin Šimák, Petra Molková

The financial volume of contributions employees) is growing, although during the remitted by the participants (i.e. net of the last three years the trend is decreasing (see employers’ contributions paid in favour of the Table 6).

Table 6. Development of the volume of participants’ contribution (thousand million CZK) net of the employers’ contributions paid in favour of the employees, and inter-annual development (%) during the period of 2000–2010

Year 2000 2001 2002 2003 2004 2005 Volume 9.084 10.040 10.957 11.770 13.146 15.335 Increase – 10.5 9.1 7.4 11.7 16.7

Year 2006 2007 2008 2009 2010 Volume 17.607 20.211 21.887 22.955 23.218 Increase 14.8 14.8 8.3 4.9 1.1

Source: Ministry of Finance CR 2005

Continuous growth within the system the state (Table 7). In 2010, the state paid in of the supplementary pension insurance is 5.51 billion CZK, which is an increase by 3.04 indicated by the annual amount paid in by billion CZK in comparison with the year 2000.

Table 7. State contributions paid during the period of 2000–2010 (billion CZK)

Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 State contri- 2.470 2.658 2.770 2.930 3.222 3.683 4.162 4.651 5.088 5.347 5.510 bution

Source: Ministry of Finance CR 2005

Weak points of the state-contributory The average age of a participant in supplementary pension insurance supplementary pension insurance oscillates In spite of the relatively favourable around 48 years of age, which is considerably development of the system of supplementary higher than the average age in the pension pension insurance, there are significant issues systems in developed countries. Younger and weak points: employees (under 40) are not covered much, which means a considerable risk as this is the • Age structure of the participants in generation which will be heavily affected by supplementary pension insurance the consequences of the planned reform of the The age structure of the participants in pension system (i.e. the pension guaranteed supplementary pension insurance does not by the state) and will be therefore more reflect the age distribution of the population, dependent on additional sources of old-age which is shown in the following overview pension. Of the total number of 4,543,125 of the development of the age structure of participants, 47% are males and 53% are the participants in supplementary pension females. insurance during the period 2005–2010 (Table 8).

180 Current problems of the czech state-contributory supplementary pension insurance

Table 8. Age structure of the participants in supplementary pension insurance and its development during the period of 2005–2010

Age Proportional share of age groups during the period of 2005–2010 2005 2006 2007 2008 2009 2010 18–29 11.63 12.60 12.63 12.70 12.61 12.36 30–39 18.35 19.09 19.98 20.60 21.11 21.33 40–49 21.50 20.46 19.74 19.20 19.10 19.16 50–59 28.38 26.91 25.31 24.20 22.94 22.04 60 and higher 20.14 21.38 22.32 23.40 24.23 25.10

Source: Association of Pension Funds of the Czech Republic 2010

• Low average contributions into the between 500 and 599 CZK monthly so that system they draw the state support in full and the The too low average contributions into the tax relief in part (the tax relief is provided for system represent a substantial weak point of contributions between 500 and 1,500 CZK), the present system of supplementary pension but they do not save much for old age. A insurance. This amount does not even reach monthly contribution higher than 1,500 CZK, the level of 2% of the average gross wage and eligible for maximum tax relief, is saved by under no circumstances would it provide nearly 6% of the participants in supplementary significant compensation for the slump in pension insurance. The development of the income connected with retirement, which average participant’s contribution and the contradicts the purpose and the primary state contribution during the period of 1995– function of supplementary pension insurance. 2010 is shown in Table 9. Most of the participants (approx. 30%) save

Table 9. Development of average participant’s contribution and state contribution during the period of 1995–2010

Year Average monthly participant’s contribution Average monthly state contribution (CZK) paid to a participant (CZK) 1995 262 93 1996 305 103 1997 333 97 1998 333 95 1999 324 92 2000 326 89 2001 340 90 2002 354 90 2003 384 96 2004 397 98 2005 408 99 2006 431 102 2007 450 104 2008 451 105 2009 444 105 2010 440 105

Source: Ministry of Finance CR 2005

181 Jan Molek, Martin Šimák, Petra Molková

In general, people should save five to ten No wonder – the interest appreciation percent of their wages for the whole time of allocated to the clients hardly compensates their productive age. Then they will be able to for inflation. eliminate the slump in their living standard At first sight, the appreciation of the savings when they retire (of course not in full) in the way it is presented by the pension funds (Sušanka 2011). looks very attractive, which is shown in the following overview of nominal appreciation • Low appreciation of savings of the savings during the period of 1995–2010 The too low appreciation of savings is a (Tables 10a, 10b) and the pension funds use fundamental problem of supplementary it quite successfully during their marketing pension insurance as it does not contribute to activities (mainly when “hunting” for new its attractiveness (for the young generation). clients).

Table 10a. Overview of nominal appreciation of the savings (in %) during the period of 1995–2002

Nominal appreciation of savings during the period of 1995–2002 (%) Pension fund 1995 1996 1997 1998 1999 2000 2001 2002 AEGON PF 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Allianz PF – – 8.90 9.10 6.00 3.80 4.36 3.71 AXA PF 12.80 11.45 11.20 10.10 6.50 4.10 4.25 3.41 ČSOB PF Progres 0.00 16.40 8.00 10.90 7.70 5.62 3.90 4.26 ČSOB PF Stabilita 10.40 10.90 10.30 10.02 6.10 4.20 3.20 3.00 Generali PF 10.30 10.61 14.60 11.40 5.30 3.60 4.60 4.10 ING PF 12.80 12.10 11.00 9.34 6.00 4.40 4.80 4.00 PF České pojišťovny 10.30 9.20 9.60 9.72 6.60 4.50 3.80 3.20 PF České spořitelny 4.00 8.10 9.05 8.33 4.40 4.20 3.80 3.50 PF Komerční banky 9.44 8.36 9.10 9.50 7.20 4.89 4.40 4.63

Source: Association of Pension Funds of the Czech Republic 2010

Table 10b. Overview of nominal appreciation of the savings (in %) during the period of 2003–2010

Nominal appreciation of savings during the period of 2003–2010 (%) Pension fund 2003 2004 2005 2006 2007 2008 2009 2010* AEGON PF 0.00 0.00 0.00 0.00 4.50 3.50 2.10 1.50 Allianz PF 3.00 3.00 3.00 3.11 3.00 3.00 3.00 3.00 AXA PF 3.36 3.10 3.70 2.50 2.20 0.00 2.00 1.50 ČSOB PF Progres 4.30 5.30 5.00 2.30 2.40 0.02 1.00 1.00 ČSOB PF Stabilita 2.30 4.30 4.00 2.80 2.40 0.05 1.37 1.40 Generali PF 3.00 3.00 3.81 3.74 4.10 2.00 2.40 2.10 ING PF 4.00 2.50 4.20 3.60 2.50 0.04 0.10 2.00 PF České pojišťovny 3.10 3.50 3.80 3.30 2.40 0.20 1.20 2.00 PF České spořitelny 2.64 3.74 4.03 3.04 3.10 0.40 1.28 2.00 PF Komerční banky 3.40 3.50 4.00 3.00 2.30 0.58 0.24 2.20

Source: Association of Pension Funds of the Czech Republic 2010

* As the data shown in the table above reflect the authors’ estimation based on the economic results achieved in the year 2010, it can’t be ruled out that some of the funds will allocate extraordinary appreciation to their clients (which was done e.g. by AEGON PF).

182 Current problems of the czech state-contributory supplementary pension insurance

However, the relatively favourable inflation rate during the period of 1995–2010 situation was fundamentally changed by is shown in the following table (Table 11). inflation (unfortunately, for the worse). The

Table 11. Inflation rate (in %) during the period of 1995–2010

Year 1995 96 97 98 99 2000 01 02 03 04 05 06 07 08 09 2010 Infla- 9.1 8.8 8.5 10.7 2.1 3.9 4.7 1.8 0.1 2.8 1.9 2.5 2.8 6.3 1.0 1.5 tion

Source: Czech Statistical Office 2011

The real appreciation of savings (i.e. the correspond to the parameters anticipated for appreciation of the savings with inclusion long-term investment (Tables 12a, 12b). of inflation) is low, and its level does not

Table 12a. Real appreciation of savings during the period of 1995–2002

Real appreciation of participants’ means (%) Pension fund 1995 1996 1997 1998 1999 2000 2001 2002 AEGON PF Allianz PF 0.40 –1.60 3.90 –1.10 –0.34 1.91 AXA PF 3.70 2.65 2.70 –0.60 4.40 0.20 –0.45 1.61 ČSOB PF Progres 7.60 –0.50 0.20 5.60 1.72 –0.80 2.46 ČSOB PF Stabilita 1.30 2.10 1.80 –0.68 4.00 0.30 –1.50 1.20 Generali PF 1.20 1.81 6.10 0.70 3.20 –0.30 –0.10 2.30 ING PF 3.70 3.30 2.50 –1.36 3.90 0.50 0.10 2.20 PF České pojišťovny 1.20 0.40 1.10 –0.98 4.50 0.60 –0.90 1.40 PF České spořitelny –5.10 –0.70 0.55 –2.37 2.30 0.30 –0.90 1.70 PF Komerční banky 0.34 –0.44 0.60 –1.20 5.10 0.99 –0.30 2.83

Source: Association of Pension Funds of the Czech Republic 2010, Czech Statistical Office 2011, our calculation

Table 12b. Real appreciation of savings during the period of 2003–2010

Real appreciation of participants’ means (%) Pension fund 2003 2004 2005 2006 2007 2008 2009 2010* AEGON PF 1.70 –2.80 1.10 0.00 Allianz PF 2.90 0.20 1.10 0.61 0.20 –3.30 2.00 1.50 AXA PF 3.26 0.30 1.80 0.00 –0.60 –6.30 1.00 0.00 ČSOB PF Progres 4.20 2.50 3.10 –0.20 –0.40 –6.28 0.00 –0.50 ČSOB PF Stabilita 2.20 1.50 2.10 0.30 –0.40 –6.25 0.37 –0.10 Generali PF 2.90 0.20 1.91 1.24 1.30 –4.30 1.40 0.60 ING PF 3.90 –0.30 2.30 1.10 –0.30 –6.26 –0.90 0.50 PF České pojišťovny 3.00 0.70 1.90 0.80 –0.40 –6.10 0.20 0.50 PF České spořitelny 2.54 0.94 2.13 0.54 0.30 –5.90 0.28 0.50 PF Komerční banky 3.30 0.70 2.10 0.50 –0.50 –5.72 –0.76 0.70

Source: Association of Pension Funds of the Czech Republic 2010, Czech Statistical Office 2011, our calculation

* As the data shown in the table above reflect the authors’ estimation based on the economic results achieved in the year 2010, it can’t be ruled out that some of the funds will allocate extraordinary appreciation to their clients (which was done e.g. by AEGON PF).

183 Jan Molek, Martin Šimák, Petra Molková

The level of the real appreciation of the volume of stock cannot exceed 25% of the savings (including the inflation) shows – asset portfolio). The fundamental barrier is especially during the first five years –a the duty to show a positive annual economic considerably decreasing trend (quasi- result (if a pension fund is loss-making, the hyperbolic function relationship). At the same stockholders must pay the difference). time, there is an inverse proportion between By law, pension funds must allocate at the amount of the savings and the level of least 85% of the revenue in favour of their their real appreciation; in other words, the clients, the reserve fund must be increased higher the annual savings, the lower the real by 5% of the revenue, and the remaining 10% appreciation (based on a model projection, may be distributed to stockholders (up to it is estimated that after approx. 40 years of now, none of the pension funds have paid out saving, with annual savings over 6,000 CZK, any dividends to their stockholders). the level of the real appreciation does not A pension fund may allocate even more reach 1%). money to their clients than the required According to Jiří Rusnok, President of above-mentioned minimum limit (like e.g. the Pension Fund Association, the low real AEGON PF). This is an effective marketing appreciation of the savings administered instrument, used to attract clients, as they by pension funds is rightfully criticised. will “respond positively” to the idea of high However, it is a kind of defrayal for the system revenue; of course they will not try to find out stability (by law, the pension funds must keep why it is so high. to at least zero nominal appreciation). The legislation ordering the pension fund stockholders to bear the risk connected with To a certain degree, the low appreciation compensation of the loss on an annual basis of the savings is influenced by the Act on (in fact, a temporary loss is not admissible), supplementary pension insurance, which determines the investment strategy of the regulates the operation of pension funds and pension funds quite strictly. The (very logical) sets numerous limits in terms of the scope of result is that the administrators prefer safe activities performed by the pension funds. investments to higher revenue. Therefore, By law, pension funds are limited in the majority portion of the pension fund allocation of investments, while the most portfolios consists of safe yet less profitable serious obstacle is not the limits set for assets, see Table 13. specific types of assets (for example, the

Table 13. Portfolio of pension fund assets as to 31 December 2010

Asset % portion Real estates 0.80 Bonds 84.00 Monies on bank accounts and term deposits 7.60 Participation certificates 3.70 Stock 0.80 Short term bonds 0.50 Other assets 2.60

Source: Association of Pension Funds of the Czech Republic 2010

The distinctively conservative investment strategy with an accent upon stock, which strategy does not give younger participants could be continuously modified into a more with a longer investment horizon much conservative one in order to “protect” the chance to choose a more aggressive gained profit.

184 Current problems of the czech state-contributory supplementary pension insurance

The reason why the legislation forces the money to their clients. However, their assets pension funds to allocate financial means (the stockholders’ assets) are connected with in a way that is not very effective (in many the clients’ assets, which makes the costs non- other countries, the funds allocate over 40% transparent and the result is devaluation of of their assets to stocks and other long- potential revenue from the clients’ savings. term investments) is probably the general According to economists from the IDEA apprehension that in older citizens who are science centre under the Economics Institute involved in the system the outputs from the of the ASCR, this is one of the reasons why proportion of “revenue versus risk” would Czech pension funds have the worst financial not result in success due to higher volatility performance in central Europe. on the stock market (stock means higher The operating costs of private pension risk but a considerable part of the risk is funds are high. Although the average eliminated by diversification and long-term operating costs compared to total assets investment). show a decreasing trend (Table 14), it is still The key factor that significantly affects the unbearable (according to the practice in other level of appreciation of savings is the related countries, costs amounting to 1% of the assets costs (in the long horizon, the costs along mean consumption of 15–20% of the amount with the inflation absorb the biggest part of of the contributions collected). The costs in the clients’ profit). At present, the pension the best pension funds in the world reach funds in the Czech Republic do not charge any 0.1% of the value that was entrusted to them official fees for administration of the collected (Švejnar 2011).

Table 14. Proportion between average operating costs and total assets administered by pension funds in the period of 1995–2010 (in %)

Year 1995 96 97 98 99 2000 01 02 03 04 05 06 07 08 09 2010 Costs 8.95 3.31 4.15 3.85 2.54 2.53 2.05 2.24 1.80 1.45 1.37 1.38 1.39 1.49 1.44 1.42 Source: Association of Pension Funds of the Czech Republic 2010

According to the estimation made by the Low number of pensions Association of Pension Funds of the Czech Another significant weak point of the private Republic, the costs of management of the pension scheme for the whole time of its financial means within the supplementary existence is the fact that the participants pension insurance consist of: mostly terminate the contractual relationship by means of a lump-sum settlement, thus the • Administration of investments number of old-age pensions assessed from 0.1–0.2% of the assets of the fund this system is very low (Table 15). In fact, the supplementary pension insurance plays the • Administration of clients role of “saving with a state contribution” and 0.3–0.7% of the assets of the fund does not fulfil its function and its mission. • Distribution and promotion There are several causes of this alarming 0.5–0.8% of the assets of the fund situation. The benevolent legislation, despite the generous state support, de facto does On principle, the highest portion of the not make the participants in supplementary costs goes to headhunting as all funds try pension insurance ever use the life-long to attract clients of other funds. This job is pensions, which lets the pension funds, done by financial consultants (who earn a making every effort to gain clients, put an lucrative commission for each new client). accent on mainly short-term advantages On the other hand, the pension funds need of supplementary pension insurance (i.e. somebody to pay for that, and the “somebody” the preference of insurance with lump-sum is the present clients (and the appreciation of fulfilment to insurance on a life-time pension their savings). basis).

185 Jan Molek, Martin Šimák, Petra Molková

Table 15. Number of pensions paid as to 31 December 2010

Pension fund Number of pension recipients, including inheritance pensions AEGON PF 47 Allianz PF 592 AXA PF 2,927 ČSOB PF Progres 390 ČSOB PF Stabilita 1,555 Generali PF 11 ING PF 772 PF České pojišťovny 563 PF České spořitelny 3,034 PF Komerční banky no data

Source: Association of Pension Funds of the Czech Republic 2010

Legal structure of pension funds The state support provided to state- As a result of the present legal structure of contributory supplementary pension insu- pension funds, the system is not transparent. rance in the Czech Republic is the highest in The stockholders’ assets are not separated from the OECD member countries. According to the participants’ assets thus the distribution expert estimation, the state support in 2010 of the profit between the stockholders and may have exceeded 11 billion CZK. Besides the the participants is not transparent (despite direct state support amounting 5.51 billion the fact that there is a formal ceiling in terms CZK, there is the tax bonus as well, i.e. a of the share of the profit to be distributed reduction of the public revenue due to the tax among the stockholders). It means that the allowance, while from the economic aspect space for drawing from the sources created this is a part of the public expenses designed by the participants in supplementary pension for pensions (Vostatek 2010). insurance is still relatively large (mainly in The state-contributory supplementary terms of the costs). pension insurance in its present condition does not fulfil its primary function. What is more, without significant support by the state CONCLUSION it cannot compete with life-cycle mutual funds or other substitute instruments offered on the In the Czech Republic, nearly 4.55 million financial market. people are participants in the state-contri- The crucial problem is that it is a product butory supplementary pension insurance fully controlled by the state (it is the state and they have saved over 216.1 billion Czech who makes decisions on legislation, i.e. crowns in pension funds. As regards the on the amounts of the state contributions, present market for supplementary pension tax bonuses and employer’s contributions insurance, there is an obvious trend towards exempted from taxation) and it is very concentration in the hands of several leading difficult to anticipate what the politicians will pension funds controlled by foreign financial push through in the future (from this point groups (the portion of the 7 largest pension of view, for the future, the state-contributory funds which belongs to 5 financial groups supplementary pension insurance de facto in the total number of the participants is represents a risky product). approximately 85%, and in the total assets of If the government, despite the conclusions all pension funds approximately 83%). As a made by the World Bank, which recommends result of this trend, the level of competition is that EU countries apply a Pan-European very low. pension system, is successful in implementa-

186 Current problems of the czech state-contributory supplementary pension insurance tion of their vision of pension reform, the group”), which means adjustment of the current state-contributory supplementary investment allocation to a participant’s pension insurance may become a product age (the fund may adjust the allocation of suitable for people who, for some reason the assets by aging of the participants so (mainly for the reason of insufficient income), that as to the date of assumed termination cannot afford to disengage from the public of the saving programme the volatility pillar in favour of the fund system (i.e. of administered financial means is the “opt-out” system) (or they will not trust minimised, which would considerably it, but they will want to save some financial eliminate an inappropriate “revenue means to improve their financial situation versus risk” proportion for different age when they retire (Holman et al. 2006). groups). If the current state-contributory supple- • It is necessary to establish a state pension mentary pension insurance is kept as a part fund on a non-profit basis (administered of the government concept of pension reform, by e.g. a special department of the it will be necessary to reform this product or Czech National Bank) that would invest to transform it into life insurance (Vostatek anywhere in the world (which would enable 2010). achieving both the highest diversification According to latest information, it seems of the risk and costs under 0.30% of the that the state-contributory supplementary value entrusted to the fund), and would pension insurance is going to be a part of become a real alternative to the present the government concept of pension reform private pension funds (whose main weak (Sušanka 2011). It is proposed that the point is, besides the low real appreciation maximum amount of the state contribution of savings, the high costs). should be increased from 150 CZK to 230 • A life-long pension must be the basic CZK. It means that the participants in fulfilment and other forms should be supplementary pension insurance would available only within precisely defined receive up to 2,760 CZK per year from the cases (partial drawing when reaching a state. To be eligible for the maximum state certain age, depending on the total amount support possible, it will be necessary to save of the money saved, etc.). Along with that, at least 1,000 CZK every month. The bill on the long-term aspect of the system must be supplementary pension insurance maintains accentuated (by increasing of the sanctions the tax allowance for the future. However, in the area of the state support, which the tax support will be applied to monthly would effectively prevent early drawing participant’s savings in the range from 1,000 from the monies being saved). to 1,500 CZK, compared to the present 500 to • The savings of a participant who dies 1,000 CZK. The aim of the proposed changes before he is entitled to annuity should, on is to strengthen the role of the supplementary principle, be transferred to the pension pension insurance in the system of creating account of the appointed person. savings for old age. • The state support should be limited to the tax bonus derived from the contribution To enable the supplementary pension remitted by a participant and his employer insurance to fulfil its primary function and (up to 10% of the average wage). The aim is become a real benefit along with the pension to increase the participant’s motivation to paid from the standard system, mainly the pay higher contributions while the direct following measures are necessary: state support is decreased. • Along with the afore-mentioned sepa- • The settlement should be burdened by ration of the assets of the pension income tax at a deduction rate of 15% funds from the financial means of their (other options may be to impose a one- participants, (for the reason of increase of off deduction tax at the rate of 15% on the financial effectiveness of the assets and employer’s contributions and entire thus increase of the real appreciation of revenues from the savings as to the date of participants’ savings), the pension funds the fulfilment, or, exemption from income must be allowed to create diversified life- tax in the case of choosing fulfilment in the cycle funds (“special funds for each age form of lifelong annuity).

187 Jan Molek, Martin Šimák, Petra Molková

• For the purpose of calculation of lifelong be implemented without preparation and annuity, a unisex death rate table should be adoption of a new legal norm. Any reform applied (at present, estimations in terms of of private pensions is an organic part of a life expectancy made by the pension funds complex pension reform and changes are fundamentally different). in the public and private pillars must be • It is necessary to introduce a system coordinated. of “guaranteed savings” in the field of supplementary pension insurance in We should not omit or marginalize case of a pension fund bankruptcy, thus another important thing, and that is the fact to strengthen the trust in the product – that reforms in the field of social security the trust in the private pension scheme (primarily pension reform) are perceived system – in the participants (the state extremely sensitively, and the proposals in should guarantee at least the participant’s this area often have to face misunderstanding contributions up to the remitted principal). and misinterpretation, resulting in protests • The safety of the system must be increased on the side of citizens, trade unions or interest (it is necessary to establish efficient groups. However, starting the reforms state supervision over the pension fund means establishing a factor that is taken into management). account in terms of assessment of fulfilment of Maastricht fiscal convergence criteria and The afore-mentioned proposals on deve- softening of sanctions for non-fulfilment due lopment of the private pension scheme cannot to reforms.

REFERENCES

1. Asociace penzijních fondů ČR. Výroční zpráva – duben 2010 [Association of Pension Funds of the Czech Republic. Annual Report – April 2010]. [online]. Praha, 2010 [cit. 2011-07-30]. Available at: http://publikace.apfcr.cz/cz_verze.html (Czech). 2. Český statistický úřad. Míra inflace [Czech Statistical Office. Inflation Rate]. [online]. Praha, 2011 [cit. 2011-07-30]. Available at: http://www.czso.cz/csu/redakce.nsf/i/mira_inflace (Czech). 3. Holman R et al. (2006). Pension Reform: Issues and prospects for Non-Financial Defined Contribution Schemes. Washington, The World Bank, p. 692. 4. Krebs V a kol. (2007). Sociální politika [Social Policy]. Edition 4, revised. Praha: ASPI, a. s., p. 504 (Czech). 5. Ministerstvo financí České republiky (2005). Závěrečná zpráva: Výkonný tým [Ministry of Finance of the Czech Republic. Final Report: Executive Team]. [online]. Praha. [cit. 2011-07-05]. Available at: http://www.mpsv.cz/files/clanky/2235/zaverecna_zprava.pdf (Czech). 6. Sušanka F (2011). Na důchod si máme spořit deset procent mzdy, radí odborníci [We Should Save Ten Percent of Our Wages for Retirement, Say Experts]. [online]. Praha. [cit. 2011-07-05]. Available at: http://www.nasepenize.cz/na-duchod-si-mame-sporit-deset-procent-mzdy-radi-odbornici-9533 (Czech). 7. Švejnar J (2011). Reforma nebude pro lidi moc výhodná [The Reform Will Not Be A Great Advantage]. Hospodářské noviny 25. 5. 2011 (Czech). 8. Tröster P a kol. (2010). Právo sociálního zabezpečení [Social Security Law]. Edition 5. Praha: C. H. Beck, p. 379 (Czech). 9. Vostatek J (2010). Panevropský penzijní systém pro Česko (návrh reformy základního penzijního pilíře, sociálních penzí a soukromých penzí včetně konkurenčních produktů) [Paneuropean Pension System for the Czech Republic (proposal on the reform of the core pension pillar, social pensions and private pensions including competitive products]. [online]. Praha, 2010 [cit. 2011-07-30]. Available at: http://www.ceses.cuni.cz/CESES-1-version1-JVppt.pdf (Czech).

188 Current problems of the czech state-contributory supplementary pension insurance

10. Zákon č. 586/1992 Sb., o daních z příjmů, v platném znění [Act No. 586/1992 Coll., Income Tax Code, as amended] (Czech). 11. Zákon č. 42/1994 Sb., o penzijním připojištění, v platném znění [Act No. 42/1994 Coll., State- Contributory Supplementary Pension Insurance Act, as amended] (Czech). 12. Zákon č. 261/2007 Sb., o stabilizaci veřejných rozpočtů, v platném znění [Act No. 261/2007 Coll. on stabilization of public budgets, as amended] (Czech).

 Contact: Jan Molek, University of South Bohemia, Faculty of Health and Social Studies, Department of Legal Branches, Management and Economy, České Budějovice, Czech Republic E-mail: [email protected]

189 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 190–197

ISSUES IN THE DEFINITIONS OF HRQoL

Elena Gurková

Comenius University in Bratislava, Jesseniuss Faculty of Medicine in Martin, Institute of Nursing, Martin, Slovakia

Submitted: 2011-07-12 Accepted: 2011-08-30 Published online: 2011-12-15

Abstract Within literature there exists confusion about the health-related quality of life (HRQoL) concept. However, clarity in the meaning of HRQoL is critically important, because confusion hinders progress in research and applications in clinical practice. HRQoL is used as an umbrella term to cover a wide range of patient reported outcomes including measures of health status, living conditions or well-being. The paper reviews the literature and discusses the important issues regarding the conceptualisation of health related quality of life in health sciences. It provides a brief description of historical development; concepts/definitions and clinical application HRQoL in health care and research. The aim of this paper is to discuss controversies or contradictory issues that currently exist concerning HRQoL and its measurement. The author proposes that future debate around HRQoL should focus from HRQoL instruments/measures to issues in HRQoL conceptualisation.

Key words: health related quality of life; quality of life; health; patient reported outcomes

Abbreviations: not only physiological measures, but also

REVIEW HRQoL – health-related quality of life subjective factors such as disease self- PROs – patient-reported health outcomes management burden, social and role QoL – quality of life functioning, burdens in performing daily QALY – quality adjusted life years activities etc. (Watkins and Connel 2004). SWB – subjective well-being Information about these outcomes can usually be supplied most accurately by the patients themselves. INTRODUCTION More recently, there has been a growing body of research concerning Traditional medical evaluation of patient endpoints that are assessed directly by outcomes with chronic diseases focuses patients and can be termed “patient- primarily on “hard” clinical outcome reported health outcomes” (PROs). It is an measures, such as clinical symptoms, umbrella term used for all patient-based lab parameters, disease complications assessments. The U.S. Department of or compliance with various aspects of a Health and Human Services, The United treatment regimen. However, clinicians, States Food and Drug Administration researchers and policymaker have come (2009) defined PRO as “a measurement to realise that these outcomes are not based on a report that comes directly adequate in assessing the impact of a from the patient (i.e., study subject) about disease or its treatment in a patient’s the status of a patient’s health condition daily life. From the point of view of the without amendment or interpretation of patient, relevant health outcomes include the patient’s response by a clinician or

190 Issues in the definitions of HRQoL anyone else”. Examples of PROs are outcomes and the social sciences were all developing such as health status, health utilities, alternative conceptualisations of the adherence to treatment, patient satisfaction population “life quality”. This resulted in three with healthcare and quality of life. distinct forms of measurement, as follows: Quality of life (QoL) represents an • Quality Adjusted Life Years (QALY): a important aspect of PROs in current health care product that shares the disciplines of and health management. Interest in quality economics and medicine. of life assessment has continued to increase • Health-related Quality of Life (HRQOL): in recent years. International activities also a product of the discipline of medicine. illustrate the increasing importance of QoL • Subjective well-being (SWB): a product of assessment and research (Grant and Dean social sciences. 2003). The United States Food and Drug While each of these three approaches Administration use QoL measurements in includes measures of health, their the process of approving new drugs. National methodologies are so different from one and international groups advocating QoL another as to yield indexes that have assessment in clinical trials research have remarkably little in common (Cummins and recognised its importance (Grant and Dean Lau 2006). Within medicine, nursing or in 2003). Interest in QoL research has resulted the health care area in general, QoL has been in a major shift in randomised clinical operationalised via the HRQoL construct. controlled trials. In addition to clinical trials, Over the past 30 years, HRQoL has evolved QoL assessment has evolved into a primary into a respect construct for evaluating the outcome measure in health services research, effectiveness of treatment in health care acute care, and chronic illness (Grant and (Ferrans 2005). Dean 2003). This evolution coincides with recent economic changes and pressures to Purpose of hrqol measurement reconcile quality care and cost effectiveness QoL is proposed as a goal for health care (Zebrack 2000, Omery and Dean 2004). (Omery and Dean 2004), as an endpoint Today QoL assessment measures are now (Gotay et al. 1992), as an outcome of routinely used to evaluate the human and treatment, and as a means of rank-ordering financial costs and benefits of different health treatments for allocating resources. The programmes and medical interventions conceptualisation and measurement of QoL (Galloway et al. 2005). A PubMed/MEDLINE are vital to health policy, evaluation research, database search for the term “quality of life” and clinical decision making (Omery and identified over 57,742 articles for the last five- Dean 2004). year period. The use of HRQoL instruments is particularly important in chronic conditions Development of the health-related where a major objective of management is to quality of life construct arrest or reverse the decline in function and When defining QoL as it applies to health quality of life. Given the wide-ranging effects care, the term Health-related Quality of Life that chronic conditions and their treatment (HRQoL) is commonly used to focus on the can have on quality of life it is perhaps not effects of illness and treatment (Ferrans surprising that there have been a large number 2005). The WHO definition (WHO 1948) of attempts to develop patient-assessed health of health was an important milestone in the outcome measures (Garratt et al. 2002). development of QoL studies within health care During the last 15 years there have been (Galloway et al. 2005). HRQoL is a primary numerous attempts to develop patient- component of QoL and is considered to be assessed measures of health outcome an important construct in describing one’s for specific diseases (disease-specific overall condition within the health context HRQoL instruments and situation-specific (Fayers and Machin 2000, Schlarmann et al. instruments) that can be used in clinical 2008). practice or research. Many controversies Cummins and Lau (2006) note that currently exist concerning HRQoL and its during the 1970s, researchers from the three measurement (King 2003). How we define disciplinary areas of economics, health care and measure the HRQoL of individuals

191 Elena Gurková reflects much of the ongoing debates related issue by describing, what they mean by QoL, QoL in general. A more basic question is, and then letting the items in their instrument Why should we study or use the concept of speak for themselves (Fayers and Machin HRQoL? This answer may be examined at 2000). the level of the individual, the health care Regarding application of HRQoL in the providers, or national health care policy health care mentioned above, clarity in HRQoL (Spilker 1990, King 2003). When addressing meaning is critically important, because the question at the level of a patient with confusion hinders progress in research and chronic disease, the answer is to improve the applications in clinical practice. This misuse quality of the individual’s life and treatment. of terminology coupled with the wealth of When evaluating a particular therapy, health measures that have been misinterpreted as care providers may evaluate QoL in clinical measures of QoL make it almost impossible to trials to differentiate between two therapies. compare studies and to determine the relative Health care providers are concerned with effects of one intervention against another QoL because it may alter prescribing habits, (Speight and Shaw 2007). treatment regimens, and the decision to cease treatment. At the national health care policy Definitions ofhrq ol level, QoL is an important concept used to Speight and Shaw (2007) note that although improve the allocation of insufficient health many of the studies reviewed the purpose to care resources to solve all the health care assess QoL, they use a variety of measures problems (Spilker 1990). which differ substantially in their content. There are several reasons why QoL Very few of these can be said to accurately assessment is included in health care. HRQoL measure the impact of disease or its treatment outcomes may be included in clinical trials regimens on overall QoL. Many clinical of treatments with curative or palliative trials in recent years have included some intent, in improving symptom relief, care, or measure of QoL, most of these measures rehabilitation. Another reason for assessing have been derived from various narrow HRQoL is to establish information about conceptualisations of HRQoL. Others appear a range of problems that affect patients. to have no conceptual framework at all. Information about QoL may facilitate patient There is no uniform definition of HRQoL. communication, and help to determine patient The debate around the definition of HRQoL preferences (Fayers and Machin 2000) and centres upon the following issues: establish a therapeutic relationship. Despite • the relationship and distinction between its importance, there is still no consensus on “health-related quality of life” and “quality the definition or proper measurement of QoL of life”; (Speight and Shaw 2007). There is a very wide • the relationship and distinction between range of definitions and interpretations of “health” and “quality of life”; QoL (Haas 1999). HRQoL can be considered • distinction between indicators and as a latent theoretical construct which cannot HRQoL predictors, or between indicator be measured directly but only indirectly and causal variables of QoL. using indicators (Bullinger and Ravens- Sieberer 1995). Within the literature there These fundamental questions remain exists confusion about what QoL is, what unresolved, resulting in contradictory contributes to QoL, and what the outcomes of definitions of the HRQoL concept. There is QoL are (Hagerty et al. 2001). There has also a general consensus in the conceptualisation been a tendency to conflate QoL with other of HRQoL as a multidimensional construct concepts, and to use the different concepts built up by three main domains. Physical, interchangeably. The most cited examples of emotional and social aspects of health are these are life satisfaction, happiness, well- commonly considered as the core domains being, health status and living conditions, all of HRQoL. These three domains follows the of which are sometimes used interchangeably WHO definition of health as a state of complete with QoL (Galloway et al. 2005). physical, mental, and social well-being, and In the absence of any agreed formal not merely the absence of disease or infirmity. definition, most investigators circumvent the In addition to these domains, economic and

192 Issues in the definitions of HRQoL spiritual domains are commonly included ments, the wording of items “I suffer from (Ferrans 2005). pain because of diabetes”; or “I have the Despite conceptual inconsistencies, there impression that I am less attractive to is a general consensus that HRQoL include others because of diabetes” would elicit the following defining attributes: perceived pain or social status, whereas • HRQoL is multidimensional (e.g. The the question “How satisfied are you with WHOQOL Group 1995, Testa and the amount of pain relief you have or Simonson 1996, Haas 1999, Ferrans 2005, how satisfied are you with your social Speight and Shaw 2007 etc.). It means relationships” would elicit an evaluation that each person thinks about different (Ferrans 2005). aspects of their life when attempting to • HRQoL involves the individual’s per- evaluate their own QoL. This suggests that ceptions of both positive and negative QoL has several dimensions, e.g. physical, dimensions (WHOQOL GROUP 1995). social and psychological, spiritual, and QoL measures are designed to capture the that respondents should be given the totality of life experiences, both positive and opportunity to rate each one subjectively negative (Hagerty et al. 2001). The ultimate (Speight and Shaw 2007). objective for assessment of HRQoL is • HRQoL is subjective and value based (e.g. enhanced well-being. Focusing on health The WHOQOL Group 1995, Testa and problems, loss of abilities, or deficits in Simonson 1996, Haas 1999, Ferrans 2005, comparison to a normative ideal do not Speight and Shaw 2007 etc.). It means that promote the positive objective of enhanced each person rates their own QoL from their well-being (Ferrans 2005). On the other unique perspective based upon their own hand, some authors are sceptical of notions feelings, experiences and priorities. People such as HRQoL and the use of generic or use their personal standards for what they disease-specific quality of life measures. consider a desirable or undesirable QoL. For example, Cummins and Lau (2006) This suggests that respondents should be argue that “HRQoL scales represent a given the opportunity to indicate whether mish-mash of medical ill-health, functional or not a given domain (e.g. working life) limitations and psychopathology”. Several is applicable to them (and to exclude studies included in the structured reviews irrelevant domains from their QoL score) of HRQoL instruments for diabetes and then to rate the relative importance (Garratt et al. 2002, Watkins and Connell of relevant domains for their overall 2004) form an implicit assumption that QoL (Speight and Shaw 2007). Personal having diabetes results in compromised evaluation provides an understanding of QoL. In fact, there is much to be learned the impact of illness from the viewpoint of by focusing on the possible positive aspects the patient, which is different from their of chronic disease-self-management. For health status. example, improved QoL may occur not • HRQoL is dynamic. It means that each only as a result of minimising perceptions person’s assessment of their own QoL of diabetes self-management as a burden, will change over time, dependent upon but as a result of maximising other possible his or her priorities, experiences and perceptions: meeting and overcoming self- circumstances at the given time. This management challenges, opportunities for suggests that at one time, for instance, an self-development, role-modelling for others individual might give greater weight to and in addressing the spiritual aspects of their ‘working life’ than at another time, health (Watkins and Connell 2004). such that QoL priorities vary within as well as between people (Speight and Shaw QoL versus HRQoL 2007). QoL is a general concept that implies an • HRQoL is defined in terms of perceived evaluation of the impact of all aspects of life on status (e.g. WHO 1995) or subjective general well-being. Because this term implies evaluation (Ferrans 2005). Both kinds of the evaluation of non health-related aspects of definitions provide subjective information life, it is too broad to be considered appropriate about a person’ life. In HRQoL instru- for a health care claim (Bradley 2006).

193 Elena Gurková

Health-related QoL is concerned with QoL health problems, health status, and health within the specific context of health (Galloway care and health-promoting activities (Padilla et al. 2005). Several authors (Spilker and and Frank-Stromborg 2004). Revicki 1996, Padilla and Frank-Stromborg 2004, Ferrans 2005) identified some issues Health versus HRQoL surrounding the HRQoL construct. One QoL was used as an umbrella term to cover issue concerns the distinction between QoL a wide range of PRO measures including and HRQoL. Fundamental questions are measures of health status which are actually associated with this issue – What aspects of measuring the quality of health and not life distinguish between QoL and HRQoL quality of life (Bradley 2006). constructs? What attributes of QoL are most Singh and Bradley (2006) present that salient to ill and to healthy people? How do “… literature is full of reports, claiming to these characteristics differ between people measure QoL using questionnaires, which in with a differing culture, functional status fact are actually measures of health status and etc.? Ferrans (2005) argues that HRQoL is measure quality of health rather than QoL. used to distinguish these aspects of life from It is likely that health status will have some those that are beyond the realm of health care, correlation with how good or bad a person such as standard of living, education, public feels their life to be, but quality of health and safety etc. Thus, QoL has a more generalised QoL are not the same thing. Efforts to achieve meaning than HRQoL. HRQoL draws a line excellent health may damage QoL”. For between those facets of life that are primarily clinicians, optimal health may be perceived health related and those that are not (Ferrans as the ultimate outcome and the one thing 2005). Spilker and Revicki (1996) developed that they can aim to influence (Singh and taxonomy for non-HRQoL, composed of four Bradley 2006). Thus, health status becomes domains: confused with QoL and is often referred to as • personal-internal (facets within the HRQoL, perpetuating the confusion (Speight individual that influence perceptions and and Shaw 2007). Therefore, results can be interactions with the environment); highly misleading if we interpret health status • personal-social (the individual’s so- measures as if they are measures of QoL (Singh cial network and immediate social and Bradley 2006). Bradley (2006) gave the environment); example of the influential UK Prospective • external-natural environment (geographi- Diabetes Study (UKPDS) as one which used cal and natural environment); health status measures but interpreted their • external-societal environment (organisa- findings as if they were measuring quality of tions and institutions created by society). life. Sawatzky (2007) notes that despite this ambiguity in the conceptualisation of quality However, Spilker and Revicki (1996) note of life, some researchers have developed that the distinction between HRQoL and non- conceptual models in an attempt to describe HRQoL is fluid, in that each component can the relationships between quality of life and became health related. In addition, when an health (Vallerand and Payne 2003, Ferrans individual becomes ill, almost all areas of life 2005). These models generally imply that the can become health related (Guyatt et al. 1989). presence of disease results in symptoms that HRQoL means that the summary of affect various so-called dimensions of quality attributes that characterise one’s life is of life, such as physical, psychological, and made at a point in time when health, illness, social functioning, which in turn contribute and treatment conditions are relevant. The to the overall quality of life (e.g. Wilson and relevant characteristics of a healthy person’s Cleary 1985). Most models also account for the QoL may not include physical, emotional presence of a variety of psychological processes or biomedically defined health, but rather (e.g., coping, adaptation and personality) and social relationships, financial success, and a social, cultural and environmental factors satisfying job. On the other hand, a person (Sawatzky 2007). whose health is threatened by acute or Based on a meta-analysis of studies that chronic illness will likely attribute certain used instruments measuring various health dimensions of life quality to the influence of status indicators, Smith et al. 1999 (cited in:

194 Issues in the definitions of HRQoL

Sawatzky 2007) showed that “... variation that identify relationships among critical in quality of life was explained by variables elements (attributes) of HRQoL and the pertaining to various life domains, which were variables that are determinants (or predictors) affected by differences in physiological health of them (Padilla and Frank-Stromborg 2004, status (e.g., the presence of disease) and Ferrans 2005). This is important because it symptom severity. Examples of life domains will allow for distinction between process and in their meta-analysis include variables that outcome variables. reflected psychological, social, or physical The following models are an illustration functioning”. Quality of life was represented of different ways of viewing the relationships by measures of life satisfaction, wellbeing and between determinants and domains of single-item quality of life indicators. Thus, HRQoL. Padilla and Frank-Stromborg (2004) their model of the determinants of quality of present that “the model proposed by Ware life is based on the proposition that the life (1984) suggest that disease has its most domains mediate the degree to which quality immediate impact on personal functioning, of life is explained by differences in symptom then psychological well-being, followed by severity and physiological health status. general health perceptions and social/role Although mental health status and physical functioning. In contrast, the model proposed function were both fairly strongly correlated by Ferrell et al. (1991) conceptualises pain with life satisfaction, a regressive quality of from cancer and its treatment as having an life on mental health, physical function, and independent impact on the HRQoL domains”. social function reveal that mental health status Wilson and Cleary (1985) described a model was by far the most important explanatory wherein physiological and psychological variable. The authors concluded that health symptoms affect functional status, which status is conceptually distinct from quality of affects general health perceptions and life (Sawatzky 2007). quality of life. Padilla and Grant (1985) In the study of people who underwent proposed the nursing model of QoL that coronary artery bypass graft surgery, Beckie depicted the dimensions of QoL as dependent and Hayduk (2004) found that “quality of outcome variables and nursing process life can be considered as a global personal activities manipulated by the investigator as assessment of a single dimension, which may independent variables. Mediating variables be causally responsive to a variety of other affecting QoL are cognitive-emotional distinct dimensions including dimensions changes in the client that enhance self- such as health” (Beckie and Hayduk 2004). perceptions and can be affected by nursing The conceptual models by Smith et al. (1999) care. As the mediating variable is regarded as and Beckie and Hayduk (2004) are based on a necessary antecedent to QoL, the nursing the premise that health and quality of life process is viewed as having an indirect impact constitute distinct concepts, and that quality on QoL. Extraneous variables are those not of life can be viewed as a one-dimensional being manipulated by the investigator but concept that is to some degree influenced by potentially affecting the outcomes, such as health (Sawatzky 2007). treatment characteristics, either in a statistical or direct way (Padilla and Grant 1985). Ferrell Determinants versus dimensions of et al. (1991) then used the Padilla model as a HRQoL conceptual framework for the development A number of conceptual models of HRQoL and testing of an instrument to measure QoL have been proposed. The majority of as an outcome variable in the management conceptual models of HRQoL (e.g. Ferrell of cancer pain. The lack of a distinction et al. 1991, WHOQOL GROUP 1995, Spilker between determinants and attributes of and Revicki 1996, Ferrans 2005) focus HRQoL in definitions of the construct leads to on the identification of domains and their conceptual and operational confusion (Padilla components. However, relationships among and Frank-Stromborg 2004). This distinction domains in these models are usually not is important for future understanding of specified, other than to say there are mutual interventions that can maintain or improve simultaneous interactions among them. The HRQoL. Padilla and Frank-Stromborg current challenge is to develop causal models (2004) gave the following example – “Pain

195 Elena Gurková is identified as a symptom of cancer or side including treatment satisfaction, health status effect of treatment that has an impact on and well-being. While each of these outcomes HRQoL. At the same time, evaluation of pain may be important for QoL, they are not QoL distress, intensity, and frequency are used as per se. The future debate around the HRQoL a basis for QoL scores. Generally, pain should should focus from HRQoL instruments to not be treated as both the cause and effect.” issues in HRQoL conceptualisation – the relationship and distinction between “health- related quality of life” and “quality of life”; the CONCLUSION relationship and distinction between “health” and “quality of life”; distinction between The term QoL has been inappropriately used to HRQoL indicators and predictors, or between refer to a variety of patient-reported outcomes, indicator and causal variables of QoL.

REFERENCES

1. Beckie T, Hayduk LA (2004). Using perceived health to test the construct – related validity of global quality of life. Social Indicators Research. 65: 279–298. 2. Bradley C (2006). Feedback on the FDA’s February 2006 draft guidance on Patient Reported Outcome (PRO) measures from a developer of PRO measures. Quality of Life Research. 4(78): 1–8. 3. Bullinger M, Ravens-Sieberer U (1995). Stand der Forschung zur gesundheitsbezogenen Lebensqualität von Kindern. Eine Literaturanalyse [State of research of health-related quality of life in children. A review of the literature]. Präv Rehab. 7(3):106–121. 4. Cummins RA, Lau ALD (2006). Using health and subjective wellbeing for quality of life measurement – a review. Social Policy Review. 18: 165–192. 5. Fayers PM, Machin D (2000). Quality of Life: Assessment, Analysis, Interpretation. First edition. Chichester: John Wiley & Sons Ltd., p. 395. 6. Ferrans CE (2005). Definitions and conceptual models quality of life. In Lipscomb J, Gotay CC, Snyder C: Outcomes Assessment in Cancer. First edition. Cambridge: Cambridge University Press, pp. 14–30. 7. Ferrell B, Zichi Cohen M, Rhiner M, Rozek A (1991). Pain as a Metaphor for Illness. Part I: Family Caregivers’ Management of Pain. Oncology Nursing Forum. 18(8): 1315–1321. 8. Food and Drug Administration (2009). Guidance for Industry Patient-Reported Outcome Measures: Use in Medical Product Development to Support Labeling Claims. [online]. [cit. 2010-09-20]: Available at: http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ default.htm 9. Galloway S, Bell D, Hamilton CH, Scullion A (2005). Well-Being and Quality of Life: Measuring The Benefits of Culture And Sport: A Literature Review and Thinkpiece. First edition. Edinburgh: Scottish Executive Social Research, p. 157. 10. Garratt AM, Schmidt L, Fitzpatrick R (2002). Patient-assessed health outcome measures for diabetes: a structured review. Diabetes UK. Diabetes Medicine. 9: 1–11. 11. Gotay CC, Korn EL, McCabe MS, Moore TD, Cheson BD. (1992). Quality of life assessment in cancer treatment protocols: research issues in protocol development. Journal of the National Cancer Institute. 84(8): 575–579. 12. Grant MM, Dean GE (2003). The evolution of quality of life in oncology and oncology nursing. In King CR, Hinds PS: Quality of Life. From Nursing and Patient Perspective. Theory. Practice. Research. Second edition. Sudbury: Jones and Bartlett Publishers, 2003, pp. 3–28. 13. Guyatt G, Mitchell A, Irvine EJ, William N, Goodacre R, Tompkins CA (1989). New measure of health status for clinical trials in inflammatory bowel disease. Gastroenterology. 96(3): 804–810. 14. Haas BA (1999). Multidisciplinary Concept Analysis of Quality of Life. Western Journal of Nursing Research. 21(6): 728–742. 15. Hagerty MR, Cummins RA, Ferriss AL, Land K, Michalos AC, Peterson M, Sharpe A., Sirgy MJ, Vogel J (2001). Quality of Life Indexes for National Policy: Review and Agenda for Research. Social Indicators Research. 55(1): 1–96.

196 Issues in the definitions of HRQoL

16. King CR (2003). Overview of Quality of Life and Controversial Issues. In King CR, Hinds PS: Quality of Life. From Nursing and Patient Perspective. Theory. Practice. Research. Second edition. Sudbury: Jones and Bartlett Publishers, pp. 29–42. 17. Omery AK, Dean H (2004). Multiple instruments for measuring quality of life. In Frank-Stromborg M, Olsen S: Instruments for Clinical Health-Care Research. Third ed. Sudbury: Jones and Bartlett Publishers, pp. 150–163. 18. Padilla GV, Grant MM (1985). Quality of life as a cancer nursing outcome variable. Advances in Nursing Science. 8(1): 45–60. 19. Padilla GV, Frank-Stromborg M (2004). Single instruments for measuring quality of life. In Frank- Stromborg M, Olsen S: Instruments for Clinical Health-Care Research. Third ed. Sudbury: Jones and Bartlett Publishers, pp. 128–149. 20. Sawatzky R (2007). The measurement of quality of life and its relationship with perceived health status in adolescents. University of British Columbia, Dissertation thesis, pp. 7-14 [online]. [cit. 2010- 09-20]. Available at: http://www.ricksawatzky.com/mslss/Dissertation_RickSawatzky.pdf 21. Schlarmann J, Metzing-Blau S, Schnepp W (2008). The use of health-related quality of life (HRQOL) in children and adolescents as an outcome criterion to evaluate family oriented support for young carers in Germany: an integrative review of the literature. BMC Public Health. 8: 414. 22. Singh H, Bradley C (2006). Quality of life in diabetes. International Journal of Diabetes in Developing Countries. 1: 7–10. 23. Smith KW, Avis NE, Assmann SF (1999). Distinguishing between quality of life and health status in quality of life research: A meta-analysis. Quality of Life Research. 8: 447–459. 24. Speight J, Shaw JA (2007). Does one size really fit all? Only by considering individual preferences and priorities will the true impact of insulin pump therapy on quality of life be determined. Diabetic Medicine. 24(7): 693–695. 25. Spilker B (1990). Introduction. In Spilker B et al.: Quality of life and pharmacoeconomics in clinical trials. Second edition. 1996, Philadelphia, PA: Lippincott-Raven Publishers, pp. 1–10. 26. Spilker B, Revicki BA (1996). Taxonomy of Quality of Life. In Spilker B et al.: Quality of life and pharmacoeconomics in clinical trials. Second edition. 1996, Philadelphia, PA: Lippincott-Raven Publishers, 1996, pp. 25–31. 27. Testa MA, Simonson, DC (1996). Assessment of Quality-of-Life Outcomes. The New England Journal of Medicine. 334(13): 835–840. 28. Vallerand AH, Payne JK (2003). Theories and Conceptual Models to Guide Quality of Life Related Research. In King CR, Hinds PS: Quality of Life. From Nursing and Patient Perspective. Theory. Practice. Research. Second edition. Sudbury: Jones and Bartlett Publishers, pp. 45–65. 29. Ware JE, Jr. (1984). Methodology in behavioral and psychosocial cancer research. Conceptualizing disease impact and treatment outcomes. Cancer. 15(53): 2316–2326. 30. Watkins KW, Connell CM (2004). Measurement of health-related quality of life in diabetes mellitus. Pharmacoeconomics. 22(17): 1109-1126. 31. WHOQOL GROUP (1995). The World Health Organization Quality of Life Assessment (WHOQOL): position paper from the World Health Organization. Social science and medicine. 4(10): 1403–1409. 32. Wilson IB, Cleary PD (1985). Linking Clinical Variables with Health-Related Quality of Life a Conceptual Model of Patient Outcomes. JAMA 273(1): 59–65. 33. World Health Organization (1948). Constitution of the World Health Organization. Geneva: WHO. 34. Zebrack B (2000). Cancer survivors and quality of life: a critical review of the literature. Oncol Nurs Forum. 27(9): 1395–1401.

 Contact: Elena Gurková, Comenius University in Bratislava, Jesseniuss Faculty of Medicine in Martin, Institute of Nursing, Malá Hora 5, 036 32 Martin, Slovakia E-mail:[email protected]

197 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 198–211

HISTORICAL DEVELOPMENT OF PROSTITUTION IN EUROPE AND ITS IMPACT ON THE CZECH REPUBLIC

Roman Bláha

University of South Bohemia, Faculty of Health and Social Studies, České Budějovice, Czech Republic

Submitted: 2011-06-21 Accepted: 2011-09-08 Published online: 2011-12-15

Abstract Various negative aspects of prostitution have been discussed in our country recently more than in the past. At the time when mankind is endangered with AIDS and it is female and male prostitutes and their customers who are one of the risk groups as regards spreading of sexually transmitted diseases, prostitution behaviour has become a subject of global interest. The objective of the thesis is to provide an overview of some important data on prostitution, its basic forms, the current as well as historical developments in Europe and their impacts on the Czech Republic. The required data were obtained through the secondary analysis of data from historical documents and legal regulations that have been issued since the times of ancient Greece and Rome, throughout the Middle Ages until today, with a special focus on the history of the Czech Republic. The outcome resulting from the thesis is the description of the specific development of issues related to prostitution with respect to the legislation in the last analysed period. Prostitution is not provided for by the law, therefore it is necessary to continue dealing with the issue. Basically, in summary, prostitution is neither permitted, nor expressly prohibited in the Czech Republic – it is not classified as a crime, but only as

REVIEW an offence in some cases. It may be stated that perfect regulation of prostitution exists nowhere in Europe. However, it is basically a rule that prostitution is neither permitted nor punishable; it is just tolerable under certain conditions, while its control fully lies within the authority of municipalities.

Key words: prostitution; legal regulation; history

INTRODUCTION in the locations where demand and supply is traditionally concentrated. Prostitution accompanies mankind du- The main causes for prostitution ring its whole history. It has been present include unsatisfied sexual desire on one in every society, i.e. also in where it is hand and acquisitiveness on the other officially proscribed and prosecuted hand. All the other motives are secondary with severe punishments. In the public and less important because if there were awareness, it has been perceived especially not customers willing to pay for sexual as a heterosexual phenomenon. This is services, the crowds of prostitutes would however not quite accurate. There is also also thin (Čech a Řezníček 1997). homosexual, bisexual and transsexual What opinions should be expressed on prostitution. However, these forms are the issues related to what is undoubtedly an less frequent, acquiring importance only everlasting phenomenon that has occurred

198 Historical development of prostitution in Europe and its impact on the Czech Republic and will occur in every social formation? A With respect to spreading of prostitution clear-cut definition is theoretically as well in some locations, problems have been as practically nearly impossible because it arising with a negative impact on everyday is difficult to distinguish prostitution from life of people living there. Especially any promiscuity in today’s liberal lifestyle. Many form of public offering of sexual services experts state that the basic difference between fills the general public with indignation, these two phenomena is motivation. In case bothers people and has a negative impact on of promiscuity which results from lacking upbringing of children and young people. chastity in sexual life, the main interest lies Concerns related to uncontrolled spreading in the erotic and sexual area, contrary to of STDs, including HIV/AIDS and criminal prostitution where money or another form activities that are often related to prostitution, of compensation is the priority, while sexual including drugs and illegal possession of interests are secondary or do not play any role guns have been expressed with a growing at all. However, there is also a socially tolerated vehemency. These concerns have been semi-prostitutional behaviour practiced presented both by experts and representatives by some women who make advantage of of the public administration. their erotic value to obtain various social Prostitution also brings along a number and material benefits. Many times it is very of problems of a purely social character. difficult to draw a parting line just between There are also cases of prostitution caused by these semi-prostitutional activities and the poverty. In the group of unqualified women typical prostitution. and girls who are employable only with Hence, it may be generally said that the difficulties, it becomes a potential source of prostitution behaviour has the following two earnings that is the most easily accessible. In characteristic features: extreme cases, it becomes acceptable or even enforced means of subsistence which whole 1. consenting oneself to a sexual intercourse families sponge on (Čermák 1992). for a consideration; And finally, prostitution practised on 2. frequent changing of partners. such a large scale also means an uncontrolled transfer of large sums of money, especially The Masaryk’s Encyclopedic Dictionary as regards foreign currencies. Untaxed from 1931 states the following definition in the income represents high financial losses for prostitution entry: municipalities and the state alike. “... in a broader, moral sense, provisioning Most persons prostituting themselves of sexual satisfaction to individual of the do not pay health and social insurance opposite sex in return for some material or premiums. The time during which they do immaterial advantage however not out of pure not pay contributions for social security is not love.” included into the required time for pension Here, the heterosexual form of prostitution entitlement; neither do they become entitled is considered where the customer is usually a to benefits arising from the sickness insurance, man and the person providing such services i.e. sickness benefits, financial support for care is a female prostitute. However, homosexual of a family member, pregnancy and maternity prostitution, which is of no less importance, compensation benefit and maternity benefits. has also been developing. According to various opinions published Basic forms of prostitution recently, prostitution may be generally Basic elements of prostitution behaviour defined as provisioning of sexual services for may already be observed in some animals. It a consideration. However, this consideration is so because animals are also able to win a does not necessarily have to be only financial copulatory partner by means of tasty bites and but also other than financial, e.g. obtaining other material gifts. a certain advantage, provision of some In a human society, prostitution has had return service or obtaining of incriminating three basic forms from the historical point of documents or protection. Recently, a signi- view: ficant cause for practising prostitution have a) host prostitution; become drugs (Kukla 1992). b) religious (sacral or temple prostitution);

199 Roman Bláha c) prostitution trade (profession) (An analysis because the Greek goddess of love, Aphrodite, of related issues... 1999). was not only the symbol of the pleasures of the flesh, but also represented the goddess of The origins of the host prostitution are beauty and sensual love. closely related to religion and faith. According Prostitution was put under the public to their conviction, people believed not only control by Solon’s laws (passed in 549 BC). that gods would reveal to them, visit them and So called dicteria were established where sex live with them, but especially that they would was practised for money; they were regulated make love to them and have children with by the state, the officers of which collected them. Therefore every guest who entered a taxes from prostitutes. Prostitution became house could also be a god. The landlord would a significant source of income for the state welcome guests kindly and, apart from food treasury and the temple devoted to Aphrodite, or overnight accommodation, he would also the goddess of love, was probably built cede his wife or daughter to a guest, feeling from the revenue generated by these taxes offended whenever this gift of his was not (Hradečný 1998). accepted. The form of the host prostitution Prostitutes in Greece were divided to three still exists today in some primitive tribes. categories which were very dissimilar to one In the period of the religious prostitution, another. The lowest position was held by the prostitution behaviour serves the purposes of dicteriades who were mostly female slaves a religious ceremony and a service provided accommodated in the houses of prostitution. to gods. On the basis of various cults (e.g. the The auletrides occupied a higher level in cult of Melite in Babylon, Aphrodite in Greece, the hierarchy and they were skilled dancers Anaite in Armenia or Astorate in Phoenicia), and blowers of the flute and they enjoyed women were ordered to offer themselves some reliefs (they were allowed to leave publicly for money which they subsequently the premises of a house of prostitution and handed over to the temple. Women or girls visit thier families). The highest category of were sitting on a specified place and were prostitutes were the hetairae (e.g. Aspasia, forced to practice sex acts with everybody who Phryne, etc.) who often were highly educated tossed a silver coin into their lap. As a part of women with rich knowledge of philosophy, sacral prostitution people were also obliged arts, and literature, interested also in politics to gether in temples where the worshippers and public matters. devoted themselves to sexual plays jointly. Besides these main terms used for At the time, public sexual intercourse and prostitutes, there were many other in Greece, orgies were not considered to be immoral or for example demiurgos (public girl), lypta exceptional, it was a prescribed ceremony and (bitch wolf), paidisthe, koriska (little girl), god-worship. Sexual organs were celebrated laikas, polos (young girl), machlos (whore), and their plastic imitations were displayed pandosia (pleased-to-give), leophoros (for during celebrations and feast days (Dufour everybody), etc. 2003). All prostitutes regardless of their class Prostitution as a trade was first practised were deprived of citizen rights and had to in temples from where it later moved to wear prescribed clothes. designated facilities – so called houses of Prostitution in Rome concentrated in prostitution. This latest evolutionary type the places where houses of prostitution of prostitution was practised publicly, it (lupanaria)were built. There were also was officially permitted and controlled or prostitutes who moved around freely, working organised in the form of guilds, as the case also as dancers (sultatrices) or blowers of the might be, and located in brothels (Luňák flute (tibicinae, fidicinae). The Romes also 1993). used the terms of meretrix (harlot), scortum, scortillum (whore, slut), quaestura mancipia Perspective of prostitution in the (slave for lust), etc. (Grant 1999). ancient Greece and Rome Prostitution was officially regulated As a very cultural and educated nation, there. An official permission (licencia stupri) the Greeks went through the period of the was required for working as a prostitute religious prostitution quite smoothly. It was and income taxes were paid to the state

200 Historical development of prostitution in Europe and its impact on the Czech Republic

(macetricium). Prostitutes were registered in The great doctor of the church, St. official registers and were deprived of their Augustin himself in his work “On Order” civic rights, furthermore they had to comply (De ordine) wrote that if there were no with prescribed requirements as regards their prostitution, the world would collapse under clothes. the pressure of fierce passions. Also the Roman Rome’s caesar, Caligula, introduced a tax lawyer, Domitius Ulpianus, acknowledged for prostitutes in the amount of one eighth of prostitution as a legal profession subjected their earnings. However, this levy had to be to supervision by the police and regulation. paid by procurers, procuresses and owners of On the other hand, Constantine the Great, houses of prostitution as well. Roman emperor, fought against prostitution A typically Roman phenomenon, which actively through organised vice squads. did not occur in Greece, was prostitution of However, because a house of prostitution was married women. The most famous Roman found nearly in every street of Constantinople woman who prostitute herself was Messalina, at the time, the achieved results were far the wife of Claudius, the Roman Emperor. from corresponding to the invested efforts She visited houses of prostitution in the red- (Augustin 2000). light Subury Street where she gave herself Prostitution played three roles in the to random visitors as a prostitute and even oldest history of Christianity: competed to see whether she would cope a) prostitutes are seen as penitent women and with more attacks by men than a renowned supporters of the new faith and some were professional prostitute. even declared saint (e.g. Mary Magdalene, Mary of Egypt, etc.); Perspective of prostitution influenced b) prostitution becomes a punishment for by Christianity the Christian faith. There were two stages With spreading of Christianity, the liberal of punishment – so called corruptela (a attitude to prostitution started to retreat and woman was raped in a house of prostitution) efforts to suppress prostitution were gaining and lupanar (a woman was dragged in a grounds. It was the Christian church that house of prostitution for good); vigorously took charge of the fight against c) monks and nuns voluntarily joined houses prostitution. The oldest profession in the of prostitution to practise a specific form of world was punished with the most severe self-denial there by humiliating themselves punishments and many Apostles, especially when prostituting themselves (Harries St. Paul, preached impassioned sermons 2010). against this sin. Therefore many ladies of pleasure converted and started to lead chaste Legal provisions governing prostitution lives. The most famous life-story is the one of in Austria and its influence on prostitution in Mary Magdalene who rejected her profession our lands and later even became a saint (Bassermann To understand further development 1993). of legal regulation of prostitution on our However, the early Christian period was territory better, it is essential to state the still characterized by overall ambivalence history of the legal regulation of prostitution of opinions on prostitution. It was because in Austria which the Czech lands had made a some religious sects (for example the part of until 1918. Nicolaites, the Karpokratians, the Adamites, Prostitution was strictly prosecuted in the Cainites, etc.) resorted back to the Austria pursuant to Article 123 of the Code religious prostitution, and especially the host of Criminal Procedure issued by Charles II, prostitution started spreading among hermits dating back to 1532. Procuring and aiding and the first monks. to adultery was punished by a notice of Also the first Christian Roman emperors expulsion or also by pillorying, cutting off ears did not entirely condemn prostitution. and whipping out of a town (Weissensteiner They perceived it as a necessary evil that 2005). accompanies mankind, but seeing in it – on In 1564, Ferdinand I issued an ordinance the other hand – a certain way out from acts according to which the mayor of the city with of violence, adultery and crime. his officials in Vienna was obliged to search

201 Roman Bláha for “reckless people”, i.e. people practising undergo regular medical examinations. prostitution and procuring, in ecclesiastical as Another rule is that prostitution may be well as patrician houses on a daily basis. practised only in permitted and registered During the reign of Leopold I, a prison was houses of prostitution or even in the street, established in Vienna in 1671 “where all (men but only on the territory of exactly defined and women) caught for their reckless life style regions. Then only such prostitution could were to be arrested in”. be prosecuted that is secret (non-registered) Maria Theresa (1717–1780) fought and has got out of the defined control. The against prostitution very hard. Prostitutes regimentation system was functioning in this and procuresses from Vienna were sent way, without any significant changes, until to Timisoara in Hungary to serve their the 20th century although the abolitionist sentence of penal servitude there, but when concept of prostitution had been spreading they were proved to have infected anybody from as early as 1875. with a venereal disease, a series of various When constitutionality was introduced in punishments were prepared for them. A Austria in 1848, prostitution became illegal prostitute was first whipped, then had her head and punishable, yet was not punished in shaved, spread with mineral tar or soot, and practice. According to s. 509 of Act No. 117 as of subsequently was tied to a pillory naked and 27 May 1852, the power to punish prostitution exposed to public shaming. Torture was also was allocated to the local police who however very frequent. Maria Theresa also established tolerated prostitution and mostly prosecuted a special commission that used various the prostitution practised in secret. collaborators and informers to actively search However, the end of the 19th century and for any cases of prostitution and procuration at the beginning of the 20th century saw an and searched suspicious houses. However, unprecedented boom of prostitution which the number of prostitutes in Vienna did not was, among other things, supported also by decrease in any significant manner; in 1782, a decisive success achieved after nearly three their number was estimated to be about ten hundred years of searching for causes of thousand (Herre 1996). venereal diseases and the discovery of methods Joseph II, Holy Roman emperor (1741– of their treatment. The greatest contributions 1790), introduced quite a different concept of to this were made by Albert Neisser (dis- fighting against prostitution and procuration. covered gonococcus, a species of bacteria He cancelled the commission established by responsible for the gonorrhea infection), Fritz Maria Theresa because, in his procedure, he Richard Schaudinn (discovered microbes of was trying to promote reeducation and the spirochaeta pallida responsible for syphilis), health-related issues of the phenomenon August von Wassermann (the author of an rather than its relentless prosecution. For effective diagnostic method – the blood example in 1774 he ordered all prostitutes in testing), and Paul Ehrlich (the author of the Vienna to be caught and subjected to a medical efficient medicine called Neosalvarsan) – examination so as it could be ascertained (Neisser 1891). whether they did not pass venereal diseases Prostitution spread considerably once that were very spread and feared at the time again during World War I; therefore the high (Magenschab 1999). command of the army issued their official It may be said that during the reign of order no. 61.381 as of 3 July 1915 which emperor Joseph II, so called regimentation, was supposed to counter the spreading of legal regulation of prostitution, was venereal diseases and result in elimination of gradually developed in Austria. According prostitution. This ordinance applied both to to the regimentation principle, the state members of the military and civilians, stating tolerates prostitution if it is practised within the following, among other things: set rules and regulations. The main rule of regimentation is registration of prostitutes by 1. The staging post headquarters an authorized administrative body – mostly (post headquarters) shall be obliged the police. On the date of her registration in continuously control all prostitutes in the respective register, a woman becomes individual districts in cooperation with a professional prostitute and is obliged to the local police (political authorities of

202 Historical development of prostitution in Europe and its impact on the Czech Republic

the 1st instance) and have them regularly Prostitution on our territory examined by military or civil medical The development of prostitution on our practitioners. These controls shall also territory may be divided to several phases as apply to female staff of disreputable seen from certain points of view, when the hotels, public houses, bars, etc. It is also most important phases may be considered ordered to make occasional raids with the to be the development of prostitution and aim to track down secret prostitutes. reeducation tendencies in the 13th and 14th centuries, prohibition and prosecution of 2. When any member of the military prostitution in the 15th and 16th centuries, contracts a venereal disease, the woman prostitution in the army, the abolitionist who was determined as the source of the conception of prostitution and research in infection must be immediately established the 20th century and last but not least the and examined by a medical practitioner. explosion in the sexual area after November 3. Women who have been diagnosed to 1989 (Malinová 1999). suffer from a venereal disease must be forcefully interned in a ward for venereal Development of prostitution in the 13th diseases at the nearest hospital having and 14th centuries local authority where they will be placed Prostitution on our territory achieved its into quarantine until they recover. significant development especially in the 13th and 14th centuries when it was related 4. Every inflow of prostitutes from the rear to establishment of cities. Newly emerging shall be contained by strict controls of cities were very attractive for roving women, passports. Suspicious women shall be both for their higher life standard and big dispatched immediately. concentration of people. Prostitutes practised 5. Prostitutes who are aware of their their profession in houses of prostitution venereal infection shall be punished as located on the suburbs of cities or behind severely as possible in case they practise their walls, they were organised in guilds and their profession without authorization subjected to official supervision. (Wiest 2003). Besides these public prostitutes in cities there was also spreading out the nomadic On 25 October 1915, a wide-ranging prostitution which was secretly practised by regulation of prostitution was completed travelling singers and roving artists. During according to which the provincial political their travels from a city to a city, they were authorities were to implement measures offering sexual services besides their artistic related to the measures taken by military productions. authorities. This prostitution regulation was However, the most spread was the issued by ministerial order no. 17.406 as of prostitution practised as a trade, which was 8 January 1916 and remained in force until 11 located in houses of prostitution. These houses July 1922 when the National Assembly in the of prostitution were called meretricium or then Czechoslovakia passed Act No. 241/1922 lupanare in official documents. In Czech Coll., on abatement of venereal diseases, they were called “domky”, “domy svodnické”, which has been in force until today. Passing “domy merhyňské”, or also “hampejzy”. The of this act brought to an end the period of latter name was derived from the German regimentation which gave way to the period word “Hahnbeisz” (der Hahn = the cock) of abolition (focusing on prosecution of and this was perhaps the reason why these phenomena accompanying prostitution). houses were marked with a depiction of a The above mentioned abolitionist move- cock. In 1276, Henry of Isernia, the notary of ment started spreading from 1875 when the Ottokar II, established one of the first houses Federation Abolicioniste Internationale (FAI) of prostitution in the Lesser Town, Prague was established. When assessing prostitution, (Kuthan 1993). this organisation emphasizes especially the Women who owned or administered moral view. On a global scale, the spreading of houses of prostitution (procuresses) were the abolitionist movement has been a matter called “svodnice”, “baratanečnice” in Czech of the last several decades. and “hoffert” in German, and they received

203 Roman Bláha the third ducat from prostitutes, i.e. one third fornication was included into “the four articles of their earnings. of Prague”, with the second article stating the Although the state and society at the time following: recognize that prostitutes may be necessary to “Let all deadly sins, especially any public a certain extent, they however consider their and other vices opposing the jus divinum, be profession to be immoral. The civil rights of properly prohibited, persecuted and rooted prostitutes are also quite restricted – they out as much as possible from those whom this have to wear prescribed clothes of the yellow concerns in every estate.” colour which distinct them from honourable In 1483, a special authority was established women, they may not participate in public in Prague to punish any obvious sins which festivities, etc. were considered to include especially Gradually, moralizers, especially priests “adultery, fornication, gluttony and other who absolutely condemned it, raised their wrongdoings and improvidences”. voices more often and strongly. However, Towards the end of the 15th and 16th together with these rejecting opinions, the first centuries, syphilis (lues, the pox) was attempts to reeducate prostitutes also start spreading in an epidemic form all over the occurring. This was exactly the field where then Europe. And because prostitution John Milíč (Czech: Jan Milíč z Kroměříže), contributes to the spreading of this infection formerly an officer of the imperial chancery to not a small extent, houses of prostitution of Charles IV, and a preacher in Prague from are closed by authorities on a mass scale. All 1363, achieved great success. Although he these measures however resulted only in a belonged among the most ardent opponents repeated proliferation of secret and itinerant of prostitution, he also made efforts to help prostitution. Any conduct of such activities repentant prostitutes at the same time. For was persecuted and punished very hard, which prostitutes who wanted to change their ways, can be proved with a historical record dating he established a refuge in a small house near back to 1509 when “great seductresses” – St. Jilji Church, where he provided them food, Margaret, the honeymaker from the Old clothes and accommodation. Those women Town, and Sigmunda – were sentenced to be would stay there until they found a job for drowned. themselves or got married to some willing Under the reign of Rudolf II, Holy Roman man who would stand security for their reeducation. According to extant documents, emperor, the public and secret prostitution Milíč thus reeducated 300 prostitutes during enjoyed their flowering once again. Even two years, however, after his death in 1374 Jeroným Makovský, the Emperor’s lord of prostitution started spreading fast once again the bedchamber, himself established a secret (Loskot 1911). house of prostitution in the Lesser Town, in the “U Tří růží” house. Persecution and prohibition of At that time, secret prostitution also prostitution in the 15th and 16th proliferated in bathhouses significantly, centuries which we can consider to be a parallel to the Concurrently with the onset of the Hussite current erotic salons. Many of these facilities movement, voices against prostitution are achieved renown not only in Bohemia but also getting stronger once again, and low morals of in Austria. laymen as well as the clergy are condemned Prostitution was not permitted in the by John Hus (Czech: Jan Hus) and Wenceslas 15th and 16th centuries; it was perhaps only Koranda (Czech: Václav Koranda). In 1419, partially tolerated, but most municipal rules at the time of uprising of Prague inhabitants and regulations punished it in various ways. against the clergy, all houses of prostitution The most frequent punishment was pillorying, known at the time were therefore attacked, whipping and branding on the forehead or demolished and prostitutes were dispersed. cheek, but for example the following sentence Concurrently with cancellation of houses is stated about “harbourers of fancy women” of prostitution, the principle that prostitution in the municipal rules and regulations valid in is an offence against chastity is being enforced, Trutnov in 1569: “Let anybody who harbours and it is punished as such. Fight against any them lose their neck.”

204 Historical development of prostitution in Europe and its impact on the Czech Republic

At the time, a special form of prostitution concept of sanctioning side effects of had been developing – the prostitution prostitution, while it stopped persecuting practised in the army. Hordes of travelling the prostitution as such. A system of prostitutes were accompanying armies in medical and police measures was developed Europe at the time, but many of them also and supplemented with enforced medical married soldiers. However, relationships examinations and treatment. This law hence established between those women and did not punish practising the business of soldiers were only loose and short-lived as prostitution but some of its cases, for example the only thing soldiers were interested in the following: was to “blow off steam” as quickly as possible and prostitutes wanted to earn as much S. 20 – Invitation to commit fornication as possible. Although commanders of the 1. Those who invite or offer themselves to then armies made efforts to eliminate the commit fornication in the manner that number of prostitutes by determining various may elicit public nuisance or offend punishments both for the women and for another’s feelings of shame. soldiers, achieved results were nowhere near 2. Those who seduce a person who has not their efforts. reached the age of sixteen years. In some armies, they even introduced a special position called “Hurenweibel”, i.e. S. 21 – Scandalous conduct of fornication an army officer or non-commissioned officer Those who conduct fornication in the manner whose task was to secure newly established that is scandalous for co-inhabitants of a army campsites so as prostitutes would not house or neighbours. get in there before the army did and would not steal all supplies stored there. One of This law also cancelled all houses of the duties of the officer was also a proper prostitution (s. 14) and all police and supervision over activities of prostitutes in the administrative measures focusing, within the army as such, while he watched them not to framework of regimentation, on supervision get accommodated directly in a campsite and over prostitution (s. 13). Concurrently, insti- their number to be maintained on the level tutes for correction of prostitutes (s. 15) that would be acceptable as much as possible, were established and a system of supervision etc. However, because there used to be about over debauched young people (s. 16) was one thousand or even more “army prostitutes” introduced. accompanying one battalion, his work was At the time, there were 1,306 prostitutes surely not easy at all (Vyhlídal 2001). in the whole republic who conducted their Especially during the Thirty Year War business of prostitution in sporting houses, (1618–48), prostitution went through its and in addition to this, there were registered boom and became a significant problem. 442 prostitutes conducting their business Although very severe punishments (torture, in the streets. In total, there were registered branding, ears and noses cut off, etc.) were 1,748 prostitutes per 13,595,816 inhabitants often applied, they did not bring any effect living on the territory of the republic. There and seemed to be absolutely ineffective (The were 13 registered prostitutes per every Criminal Code of the Republic of France, 100,000 inhabitants. Together with secret 1995). prostitutes, their real number was however estimated at 10,000 (Dufour 2003). The abolitionist conception of In the 1920s, extensive police records of prostitution in the 20th century prostitutes were developed and subsequently The regimentation of prostitution that was supplemented in a continuous manner; the applied in our region during the period until modified system of the records was still in use 1922 was based, together with persecution until recently. of illegal prostitution, on adopted Austro- In 1940–45, the records of prostitutes Hungarian legal regulations. were unfortunately instrumental to German Act No. 241/1922 Coll., on abatement of occupation authorities in their forcible venereal diseases terminated the period of elimination of so called “professional criminal regimentation and enshrined the abolitionist activities”. Prostitutes with a clean criminal

205 Roman Bláha record were integrated to the working process Offences, about 300 to 350 prostitutes were but those who also committed other crimes or prosecuted for social parasitism annually, but offences were taken into “protective custody” the result of the subsequent decriminalisation and gradually sent to detention concentration of this phenomena was that prostitution could camps to be “reeducated” there. However, not be punished in fact (the only exception institutions were established in Germany itself was the crime of sexual abuse according to at the time of the war, which had no parallel s. 242 of the Criminal Code when a sexual in the civilised world. They were camps called intercourse is conducted with a person under “stud farms”, officially also sometimes termed 15 years of age). as “Houses of Life” where selected young However, Act No. 67/1993 Coll. of the Czech women and girls were placed temporarily and National Council amends and supplements get covered by well-fed and sexually deprived Act No. 200/1990 Coll., on offences, of the soldiers. The purpose of the project, which Czech National Council, Act No. 283/1991 was naturally applied only to women who met Coll. of the Czech National Council, regulating the racial requirements, was procreation of the Police of the Czech Republic, and Act children of the Aryan race who were placed in No. 533/1991 Coll. of the Czech National the custody of the state (the Criminal Code of Council, regulating the municipal police, and the FRG... 1996). new states of facts are introduced for some After 1945, prostitution was prosecuted offences. Therefore, prostitution as well as especially pursuant to Presidential Decree procuring may be prosecuted as an offence No. 88/1945 Coll., on general working duties, under certain circumstances. so that the then national committees could effectively prosecute persons avoiding proper Explosion in the sexual area after 1989 work (i.e. including prostitutes, among other The democratic developments after the people). November revolution brought along not Once again, the provisions of s. 72 and s. only an enriched offer of sexual services, but 134 of Act No. 88/1950 Coll., the Criminal also an overall emancipation in this area. Administrative Procedure Code, did not Significant changes may be seen in sexually punish prostitution as such but only the alternative groups such as homosexuals when manner of obtaining means of support. The homosexual contacts start being advertised amendment to this Act from 1956 included for the first time (for example in the Annonce s. 188a that formulated the state of facts of magazine), various movements come to the crime and was aimed at people who were existence (for example Lambda), and even socially useless, had a bad attitude to work the possibility of legal relationship between and were capitalizing on results of work of persons of the same sex is considered (The others (the act as of 12 July 1950). National Strategy of Fight... 2008). In 1961, new Criminal Code No. By cancelling the provisions on social 140/1961 Coll. was passed, taking over s. parasitism according to s. 203 of the 188a from the old Criminal Code with some Criminal Code, the emancipation process was minor adaptations, and its newly designed eventually completed in the legal manner. provisions of s. 203 – social parasitism – This put an end to the pretence of engagement had been preserved without any substantial in the working process and the camouflage changes until 1990. The provisions of s. 10 of surrounding offers of sexual intercourse. Act No. 150/1969 Coll., on offences, that was However, simplification of the supply of sexual also aimed against social parasitism, enabled services, minimization of possibilities for the to prosecute prostitution, too. police intervention and increasing of the costs After the November revolution, Act of living caused considerable pauperisation No. 175/1990 Coll. was passed, cancelling (decreasing economic standard, growing provisions of s. 203 of Criminal Code No. poorer) of prostitution. It was so because 140/1961 Coll. and provisions of s. 10 of Act the focus of the supply of sexual services No. 150/1969 Coll., on offences, with effect moved from wine bars, hotels and bars to from 1 July 1990. the streets where Roma women participate According to former provisions of s. 203 in the activities mostly, and prostitution of the Criminal Code and s. 10 of the Act on became socially annoying and dangerous.

206 Historical development of prostitution in Europe and its impact on the Czech Republic

The unbearableness of the situation notifies Where and how is it possible to make a the behaviour that considerably overstep the paid sexual contact in our country? There is borders determined by the Civil and Criminal the whole range of possibilities and places. Codes (The Initial Study on the Issues of Houses of prostitution are only one of many Prostitution, 1968). forms of sexual intercourse provided against The growing gravity of the increasing payment. It is even imposed on a foreigner number of crimes resulted in the pressure by supplying foreign currency, especially when the general public on the police protection he stays in a luxury hotel. Exceptionally, a rich to be developed in a more thorough manner. local national may also get his money’s worth, Therefore, the city (municipal) police came to with the lowest, truly patriotic price is CZK existence that, together with the Police of the 1,000. Wishes of local nationals are respected Czech Republic, brought at least a seeming also in the places which are less exclusive such order to city streets. The decisive sphere as wine bars (in Prague, it was Narcis until that did not express their opinions on this recently), bars or railway restaurants, or such phenomena for a long time, finally came up services are offered directly in the streets. In with two approaches: our capital city, it is the “Bermuda Triangle” which is quite renowned and comprises of a) the highly progressive one, which would Rytířská and Perlová streets and Uhelný trh. integrate prostitution into the commercial Prices are more affordable here; depending register; on the nature of provided sexual services, they b) the highly repressive one, which would range from CZK 200 to CZK 500. Currently, prohibit prostitution and anything else the span of prices for a sexual intercourse is related to it (The Proposal of Measures to far more extensive as they range from EUR 5 Solve the Issues... 2000). to EUR 250 and more. After the November revolution, one of The demand for sexual services in our the first requirements voiced by our citizens country is high which has been naturally was that houses of prostitution should be reflected in the range of supply. Because reopened. Thus, the Czech citizen required financing of prostitution and procuring is paid sex to be also available to him, not only prohibited, sexual supply has acquired a to foreigners supplying foreign currency. new form – the position of a traditional Therefore, it was advisable to explain the issues sexual intercourse has been newly occupied to the general public, i.e. to draw attention not by eroticism. Thus, such institutions as only to the legal aspects of the matter but also massage salons, erotic clubs, etc. may come to the existing wide spectre of supply of sexual to existence, and any service may be obtained services (Paláček and Malinová 1993). here in practice, save for penis-vaginal and It was necessary to inform the general anal forms of intercourse. According to public about the reasons why houses of specific wishes of customers, prices here prostitution may not be established in our achieve the level of CZK 500 and more. Many conditions. This was so because we signed the of these businesses however provide “home “Convention on Action Against Trafficking delivery services” and here it only depends on in Human Beings and Making Benefit from agreement between a customer with an erotic Prostitution of Another Person as of 25 July worker what type of sexual services she will 1951” to which Czechoslovakia acceded on provide to him. 14 March 1958 and which states, among other The main domain of the “hardcore sex” thing, the following: has however become the street prostitution which is the most affordable and a citizen of The parties to this Convention shall be our republic may afford it from time to time, obliged to punish anybody who: too. Because bars and hotels are overcrowded 1. operates or manages or intentionally at the moment, the current number of girls finances or participates in financing of a and women practicing prostitution in streets house of prostitution; has already prevailed over the number of 2. consciously rents or sublets a building those who make contacts in erotic clubs. or another place or their parts for the Because street prostitution is still on purposes of prostitution of other persons. demand for many reasons, it is and probably

207 Roman Bláha will remain the existing social reality for Municipality of Dubí won recognition for some time. Its popularity and extensive use its pioneering solution of the issue and the is not determined only by its relative financial ordinance of the Council of the City of Dubí affordability. The customer may also examine thus became the basis for further regional a woman, see her in motion, watch the areas regulaion of the issues in question because he is interested in, yet remain anonymous similar ordinances were passed by other until “he makes up his mind”. Apart from that, municipal authorities, e.g. by the Municipality other unnecessary expenses spent on food and of Děčín and others. drinks or possible expenses for a hotel, etc. In the South Bohemia Region, such A potential customer mostly knows an ordinance was first passed by the where to look for sexual services. They are Municipality of Kaplice and was followed by either streets targeted by authorities or, in the Municipality of České Velenice and others other words, places where prostitution is (Svatoš 2010). permitted – the zoning determined by official At the moment, the issues of prostitution order, or the places that come to existence are considered by an initiative group of spontaneously as a result of tradition or flows Members of Parliament who have been of foreigners – the natural zoning. preparing a legal regulation that would provide Of course, practice necessarily required for this area with general effect. The objective the issues related to prostitution to be solved of this regulation should be subordination of somehow. However, because competent prostitution to the trade regime and enabling legislative bodies of our country have not it to be practiced officially in the form of paid passed any regulation with general validity sexual services. The time shows and will and effect for the whole territory of the Czech show us the final outcomes of this activity of Republic yet, municipal councils in the areas Members of Parliament. where prostitution is the biggest problem are forced to pass regulations governing the The current situation in the area of practice of prostitution at least regionally prostitution (Trávníčková 1996). In August 2000, a working meeting of 25 The first municipal ordinance issued by mayors of municipalities affected with the Council of the City of Dubí awakened an prostitution was held in Cheb. The meeting interest of other municipalities, especially adopted the “Declaration of the Cities and those contending with the issues of street and Municipalities Participating in the Meeting highway prostitution (especially along E50 on the Issues Associated with Prostitution” and E55 highways). Although the Office of which was addressed to the President of the the General Prosecutor of the Czech Republic Republic, the Prime Minister, Members of declared this ordinance null and void and Parliament and Senators of the Parliament of sent their opinion to the Council of the City the Czech Republic. of Dubí, stating that the ordinance might not The declaration requires the following: be applied henceforth, yet they changed their 1. Legal conditions regulating prostitution legal opinion soon. The General Prosecutor and phenomena related to it to be created withdrew his notice, stating concurrently that in an accelerated manner. the procedure applied by the Council was 2. A regimentation attitude to be adopted justified and adequate to the local situation. with respect to the solution of prostitution- (The activities of the Prosecutor General’s related issues. Office in the Czech Republic pursuant to Act 3. Enforceability of law to be increased, No. 60/1965 Coll., on the state prosecution especially in the case of repeated offences. service, the powers of which included the 4. Competences of municipalities to be authority to declare ordinances null and increased in the area of prostitution void, was substituted with Act No. 283/1993 regulation. Coll., on state prosecution, while the activities related to general supervision were transferred Prostitution brings nothing else except to regional authorities that were established problems to municipalities. Street and by Act No. 347/1997 Coll., on establishing highway prostitution is perceived as the higher territorial self-governing units). The most problematic because it is accompanied

208 Historical development of prostitution in Europe and its impact on the Czech Republic with problems in the area of public order burden of proof lies on an administrative disturbance, corrupting the morals of body. As it was stated herein above, the tool children, littering streets and public spaces for restricting any negative manifestations of (for example with discarded preservatives, prostitution is provided in Act No. 128/2000 litter, used sanitary towels, etc.) and problems Coll., on municipalities. Provisions in s. 10 in transportation (for example violation of of this Act authorize municipalities to issue the “No stopping” and “No parking/waiting” generally binding ordinances to regulate traffic signs, high accident frequency, prostitution in public spaces that they may disruption of smooth traffic, etc.). Prostitution pass within their own competences to secure radicalizes attitudes of the population, local order. However, it is a problem to degrades the reputation of a city in the eyes of implement such ordinances in practice or, as local and foreign tourists, exhausts the social the case may be, to enforce sanctions imposed system of a city and brings along health and in an administrative procedure, and to ensure criminal risks. that offenders participate in an administrative Some municipalities assented to issuance procedure. of an ordinance to secure local matters with This leads to an increasing debt on the respect to the public order and to eliminate account of the local administration caused or ban offering, practicing and searching for by unenforced penalties, and to unnecessary prostitution. However, application of such burdening of workers of municipal autho- ordinances in practice is disputable. The most rities, the municipal police and the Police visible problem is public order disturbance of the Czech Republic (e.g. since 1992, the by people offering prostitution services in debt of the Municipality of Chomutov has public spaces of cities and municipalities. amounted to more than CZK 1,000,000 from Prostitution practiced in private buildings unenforced penalties for offences related to that are, in addition to this, situated to prostitution, the debt of the City of Dubí is peripheral parts of cities or to secluded CZK 2,837,300). locations outside municipalities causes fewer Nowadays, neither the public admi- problems. The qualified facts of offered sexual nistration nor the Police of the Czech services according to s. 47 (1) (ch), which Republic have any tools available to regulate enabled an offence to be heard on the spot prostitution outside municipalities on roads, within the ticket procedure, were deleted parking lots, truck rest areas, wood paths, from the Act on Offences by Act No. 279/1995 public transport stops, etc. Coll. In case an offence had not been heard Prostitution practiced in erotic clubs within a ticket procedure, it was announced to is evaluated as less problematic or even an administrative body and the Police of the unproblematic. This means the only major Czech Republic had to take necessary steps benefit for municipalities – that prostitution according to s. 58 (2) of the Act on Offences has been concentrated in erotic clubs and to establish and secure the body of evidence does not exist in the streets. necessary to prove an offence. By cancelling The only problem of a more serious this provision, it was left up to municipalities to character is noise disturbance. After having solve the prostitution-related issues by means left erotic clubs, customers throw around of their generally binding ordinances issued dust bins, shout, kick people’s doors, urinate within own competencies of a municipality. on doors and facades of houses, bang on Currently, s. 46 (2) of the Act on Offences windows on ground floors, use car horns may be applied to any breach of an ordinance without justification, pull away rapidly, issued by a municipality, and a fine up to CZK etc. Persons practicing prostitution cause 30,000 may be imposed for its violation. It is offence to people and corrupt the morals of not an offence that must be investigated by children by offering themselves in windows the Police of the Czech Republic any more; – show windows of some erotic clubs or by they only inform an administrative body loud music. This situation is caused by non- about it. The Police of the Czech Republic existing competence of a municipality to may deal with it within the ticket procedure. regulate positioning and appearance of an In their notice, they only state circumstances erotic club. under which an offence was committed. Any

209 Roman Bláha

CONCLUSION It is obvious from what was stated herein above that prostitution-related issues may be In his thesis, the author has given an overview regulated in the following two basic ways: of the historical development of prostitution a) a separate legal regulation on prostitution under European conditions from ancient control, conditions of its practicing, etc.; times until today, both in the legislative b) amendments to individual acts regulating, respect and the respect of real development. in individual areas, social relationships related to issues of prostitution practicing.

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 Contact: Roman Bláha, University of South Bohemia, Faculty of Health and Social Studies, České Budějovice, Czech Republic E-mail: [email protected]

211 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 212–218

SIGNIFICANCE OF NITRATE, NITRITE AND NITROSAMINES IN NUTRITION BEDEUTUNG VON NITRAT, NITRIT UND NITROSAMINEN IN DER ERNÄHRUNG

Miroslav Stransky

Frohburgstrasse 47 a, 8006 Zürich, Schweiz

Submitted: 2011-10-10 Accepted: 2011-10-20 Published online: 2011-12-15

Abstract Nitrate is a natural and essential part of plants, its concentration in plants depends on a number of factors. Its compounds are used in food industry as preservatives. In production of cheeses, nitrate additive prevents formation of gases. The main source of nitrate in foodstuffs is vegetables, drinkable water and pickled products. Foodstuffs usually contain immaterial amount of nitrite, the source is mainly pickled meat products. Endogenous formation of nitrite from nitrate is however of substantially greater significance. In stomach, nitrite forms nitrosamines together with amines, amides and amino acids that have carcinogenic effect. The concentration of nitrate, nitrite and nitrosamines in pickled products has reduced significantly in the recent years. The health risk based on the current reception of nitrite, nitrate and nitrosamines through foodstuffs is considered very low.

Key words: nitrate; nitrite; nitrosamines; metabolism; significance; evaluation REVIEW

Einleitung Ergebnisse der Studien aus den letzten Jahren zeigen, dass das Risiko einer Ge- Aus Sicht der Prävention empfiehlt es sundheitsgefährdung durch eine zu hohe sich, den Obst- und Gemüsekonsum zu Nitrataufnahme vor 20 Jahren zu hoch erhöhen, denn viele der darin enthaltenen bewertet wurde. Stoffe besitzen eine schützende Wirkung gegen verschiedene chronisch-degenera- Nitrat tive Erkrankungen, wie z. B. Tumore und Nitrat ist ein natürlicher und unentbe- Herz-Kreislaufleiden. Seit vielen Jahren hrlicher Bestandteil von Pflanzen, die beschäftigen sich die Verbraucherschut- den Stickstoff aus Nitrat zur Synthese zorganisationen in verschiedenen Län- von Eiweiss, Nukleinsäuren und anderen dern mit dem Nitratgehalt in Gemüse und Substanzen benötigen. Deshalb wird Nit- Trinkwasser und dem Nitrosamingehalt rat in der Landwirtschaft als Dünger ein- in Fleischprodukten. Zahlreiche Verbrau- gesetzt. Seine übermäßige Verwendung cherstudien in verschiedenen mitteleu- kann zur erhöhten Nitratkonzentration ropäischen Ländern ergaben, dass der im Grundwasser und demzufolge auch Gemüsekonsum in den Wintermonaten im Trinkwasser führen. Der Nitratgehalt sinkt, nicht zuletzt auch infolge der Me- in Pflanzen hängt von seinem Gehalt im dienberichte über Überschreitungen der Boden und von den klimatischen Bedin- Nitrat-Toleranzwerte im Gemüse. Die gungen ab; bei Lichtmangel speichert die

212 Significance of nitrate, nitrite and nitrosamines in nutrition

Pflanze mehr Nitrat als bei hoher Lichtinten- Natrium- und Kaliumnitrat werden in sität. So hat das Gemüse aus Nordeuropa ei- der Lebensmittelindustrie zu Konservie- nen höheren Nitratgehalt als solches aus dem rungszwecken verwendet, insbesondere Mittelmeerraum. Auch das außerhalb der zur Herstellung von gepökelten Produkten Saison und in Gewächshäusern produziertes (Schinken u. ä.). Zur Fleischbearbeitung wer- Gemüse hat einen höheren Nitratgehalt. Der den Nitrat und Nitrit eingesetzt, welche die Nitratgehalt ist in den Wurzeln höher als in rote Farbe des Fleisches fixieren und vor ne- den anderen Pflanzenteilen, weil die Pflanze gativen Wirkungen der Bakterien, vor allem es über die Wurzeln aufnimmt. Den höchs- Clostridien schützen. Beim Pökeln wird das ten Nitratgehalt weist das Blattgemüse sowie Nitrat zu Nitrit und Stickoxid reduziert. Als einige Sorten von Wurzelgemüse auf. Die wichtige Katalysatoren dienen mikrobielle Fähigkeit, Nitrat zu binden ist jedoch sehr un- Enzyme und Myoglobin (Ebermann und El- terschiedlich, sodass der Nitratgehalt bei glei- madfa 2008). cher Gemüseart variieren kann (Elmadfa und In gepökelten Fleischprodukten ist der Leitzmann 2004). Nitratgehalt heute niedriger als früher. Die Einen hohen Nitratgehalt (>1000 mg/ veröffentlichten Ergebnisse der chemischen kg) haben Chinakohl, Eisbergsalat, Endivien, Analysen von Fleischerzeugnissen aus Öster- Feldsalat, Fenchel, Kopfsalat, Radieschen, reich zeigen einen durchschnittlichen Nitrat- Rettich, rote Bete, Ruccola, Spinat, Stangen- gehalt bei Speck von 115 mg/kg, bei Rohschin- sellerie, Mangold, Wirsing, Weißkohl (Tab. 1). ken von 71 mg/kg, bei Trockenfleisch von Einen mittleren Nitratgehalt (≤1000 mg/ 56 mg/kg, bei geräuchertem Fleisch von kg) haben Aubergine, Zucchini, Bohnen, Kür- 73 mg/kg und bei den meisten Wurstwaren bis, Brokkoli, Blumenkohl, Karotten, Lauch. von 40–50 mg/kg (AGES 2003–07b). Einen niedrigen Nitratgehalt (≤250 mg/ Ebenfalls Hartkäse und Halbhartkä- kg) haben Obst, Getreide, Erbsen, Zwiebel, se kann Nitrat enthalten. Bei Käseherstel- Knoblauch, Tomaten, Paprika, Gurken, Ro- lung verhindert der Zusatz von Nitrat die senkohl, Pilze, Spargel, Kartoffeln, Pastinake, Gasbildung (Weiss 2008). Der Nitratgehalt Milch und Milchprodukte, rohes Fleisch und schwankt zwischen 3 und 20 mg/kg (Trischler Fisch. 2006). Darüber hinaus wird Nitrat auch beim Eier, Fette und Öle enthalten kein Nitrat. Einlegen von Heringen und Sprotten verwen- det. Die Verwendung von Nitrat und Nitrit zu Konservierungszwecken bei Lebensmittelher- Tab. 1. Nitratgehalt im Gemüse (AGES stellung wird durch die Verordnung (EG) Nr. 2003–07a) 1333/2008 des Europäischen Parlaments und des Rates über Lebensmittelzusatzstoffe ge- Gemüse Probenanzahl Gehalt (mg/kg) regelt. Für die Säuglingsnahrung gilt zusätz- Brokkoli 2 366 lich die Verordnung Nr. 1881/2006, die als maximal zulässige Menge 200 mg/kg festlegt Chinakohl 3 1 098 (Verordnung 2006). Für die Konservierung Blumenkohl 1 280 können Natrium- und Kaliumnitrat sowie Karotten 159 146 Natrium- und Kaliumnitrit in Konzentratio- Kartoffel 2 17 nen von 50 mg/kg im Endprodukt verwendet werden. Wirsing 2 630 Der in der Nahrung enthaltene Nitrat und Kürbis 1 410 Nitrit stammt im Durchschnitt zu 70 % aus Radieschen 21 2 406 Gemüse, zu 20 % aus Trinkwasser und zu 10 % aus Fleischprodukten (Elmadfa und Leitz- Ruccola 104 4 674 mann 2004, Rauscher-Gabernig et al. 2010). Kopfsalat 903 1 432 Die Aufnahmemenge liegt in Europa bei 52– Spinat 169 1 649 156 mg/Tag. Bei Personen mit hohem Gemü- Portulak 1 638 sekonsum ist die Aufnahmemenge bedeutend höher: in einer englischen Studie wurde bei Zucchini 2 720 Vegetariern eine Tagesaufnahme von 185–195

213 Miroslav Stransky mg/Tag festgestellt, bei Personen mit hohem linge unter 3 Monaten, die bedeutend emp- Salatkonsum wurden ähnliche Werte ermit- findlicher auf Nitrat und Nitrit reagieren. telt (European Commission 1997). In man- Das Nitrat konkurriert im Organismus chen Gebieten gilt das Trinkwasser als eine dem Jod und kann daher die Jodspeiche- wichtige Nitratquelle. Die Verwendung von rung in der Schilddrüse beeinträchtigen. Nitrat zu Konservierungszwecken spielt in der Eine Schilddrüsenvergrösserung ist nur bei Gesamtaufnahme eine untergeordnete Rolle. Jodmangel und einer gleichzeitigen, lang an- Das Nitrat wird im Körper fast vollstän- dauernden Nitrataufnahme möglich. Für die dig resorbiert; 60–70 % werden in unverän- strumigene Wirkung ist eine Nitrataufnah- derter Form über die Niere ausgeschieden, me ab 3,65 mg/kg Körpergewicht notwendig etwa 25 % kommen durch den entero-oralen (Hampel und Zöllner 2004). Kreislauf über den Speichel in den Mund und können hier oder im Magen zu Nitrit re- Nitrit duziert werden. Weitere 5–15 % werden von Die Lebensmittel enthalten in der Regel nur der Dickdarmschleimhaut sezerniert. Etwa geringe Mengen an Nitrit, eine Quelle stellen 1 mg Nitrat pro kg Körpergewicht wird endo- vor allem gepökelte Fleischerzeugnisse dar. gen aus Stickstoffmonoxid gebildet (es gibt Eine viel größere Bedeutung kommt jedoch mehrere Stickoxide, hier handelt es sich um der endogenen Bildung von Nitrit aus Nitrat das Stickstoffmonoxid), das im Körper aus zu: Das Nitrat aus Lebensmitteln wird von den der Aminosäure Arginin entsteht. Das Sticks- Bakterien im Mund und im Darm teilweise zu toffmonoxid ist eine stark reaktive Substanz; Nitrit umgewandelt. Durch den entero-oralen die Halbwertzeit beträgt nur einige Sekun- Nitratkreislauf (siehe oben) werden inner- halb von 24 Stunden etwa 6–7 % Nitrat aus den, deshalb ist es am Ort seiner Entstehung Lebensmitteln zu Nitrit umgewandelt. Der wirksam. Es entsteht im höheren Masse in Anteil an dem so entstandenen Nitrit entsp- den Makrophagen und dient zur Bekämpfung richt 90 % der Gesamtmenge im Organismus, von pathogenen Mikroorganismen, deshalb nur 10 % stammen aus Lebensmitteln. Das wird es bei Fiebererkrankungen in großen Ausmaß der endogenen Nitratreduktion ist Mengen freigesetzt. Das Stickstoffmonoxid individuell sehr unterschiedlich; bei erhöh- kann sich auch in anderen Organen bilden. ter Nitrataufnahme steigt er sehr schnell an Es erweitert die Blutgefässe und regelt somit und bleibt einige Stunden auf hohem Niveau den Blutdruck. Darüber hinaus fördert es die (Weiss 2008). Die herabgesetzte Produktion Wundheilung und dient im Nervensystem an Salzsäure im Magen führt zur erhöhten als Neurotransmitter. Das Stickstoffmonoxid Nitritbildung. wird im Körper zu Nitrat und Nitrit umge- Auch in Lebensmitteln kann eine Umwan- wandelt und in dieser Form ausgeschieden. dlung von Nitrat zu Nitrit stattfinden. Sie Die Toxizität von Nitrat ist sehr niedrig, hängt von der Menge der in den Lebensmit- seine letale Dosis beträgt 15 g. Die Toxizität ist teln enthaltenen Bakterien, der Lagerdauer, durch seine Umwandlung zu Nitrit über den der Temperatur, dem pH-Wert, der Sauers- Speichel und durch die mögliche Bildung von toffzufuhr und dem Fermentationsvermögen Nitrosaminen im Verdauungstrakt gegeben der Mikroorganismen ab. Durch die richtige (Elmadfa und Leitzmann 2004). Die WHO Behandlung von Lebensmitteln kann die Nit- empfiehlt als Obergrenze für die tägliche Nit- ritbildung tief gehalten werden (Weiss 2008). rataufnahme 3,65 mg/kg Körpergewicht. Aus Deshalb sollten nitratreiche Nahrungsmittel langfristigen Tierversuchen wurde ein ADI- (Spinat, Pilze) bei niedrigen Temperaturen Wert (Acceptable Daily Intake) für Natrium- gelagert und schnell konsumiert werden. nitrat von 5 mg/kg Körpergewicht und für Die Nitritbildung in Lebensmitteln kann Natriumnitrit von 3,7 mg/kg Körpergewicht auch notwendig sein, z. B. beim Pökeln ist es (JECFA 1996) abgeleitet. Diese ADI-Werte Voraussetzung für die erwünschte Wirkung blieben aufgrund der neuen Studien unverän- dieser Konservierungsmethode. Deshalb en- dert (JECFA 2002, EFSA 2008). Die tole- thält das Pökelsalz neben Kochsalz und Nitrat rierbare Obergrenze für die Nitritaufnahme auch 0,3–0,5 % Nitrit. Dieses Salz stabilisiert beträgt 0,07 mg/kg Körpergewicht (JECFA die durch das Myoglobin bedingte typische 2002). Die ADI-Werte gelten nicht für Säug- rote Farbe des Fleisches, in dem es das

214 Significance of nitrate, nitrite and nitrosamines in nutrition

Myoglobin zum Nitrosomyoglobin umwan- Nitrit ist seine Bindung an sekundäre Amine, delt. Dadurch entsteht auch das charakte- mit denen es karzinogene Nitrosamine bil- ristische Aroma des Produktes. Gleichzeitig det. Ein kausaler Zusammenhang zwischen wird das Wachstum von pathogenen Mikro- der Aufnahmemenge und der Krebsprävalenz organismen, vor allem Clostridien gehemmt wurde jedoch nicht eindeutig nachgewiesen und dadurch die Haltbarkeit des Produkts (European Commission 1997, WHO 2003). verlängert. Das Pökeln verhindert die Oxida- Der Wissenschaftsausschuss für Lebens- tion von Fettsäuren und verzögert das Ranzi- mittel der EU legte für Nitrit einen ADI-Wert gwerden von Fetten (Schmid 2006). von 0,06 mg/kg Körpergewicht fest, der un- Die durchschnittliche Nitritaufnahme ter dem von der WHO festgelegten Wert von durch Lebensmittel liegt in Europa bei 0,7– 0,07 mg/kg liegt (European Commission 4,2 mg/Tag (European Commission 1997). 1997, WHO 2003). Das Nitrit wird im Verdauungstrakt schnell Das Nitrit hat aber auch positive Wirkun- resorbiert und über Hämoglobin zu Nitrat gen auf den Organismus: Im sauren Magen- oxidiert. Die Halbwertzeit beträgt im Durch- milieu entsteht aus Nitrit Nitrogenoxid, das schnitt 30 Minuten. eine antimikrobielle Wirkung hat und pa- In hohen Dosen wirkt Nitrit toxisch. Es thogene Mikroorganismen aus der Nahrung bindet sich als Methämoglobin an das Hämo- inaktiviert, insbesondere Yersinien, Salmo- globin und blockiert den Sauerstofftransport nellen, Shigellen, E. coli und Helicobakter ins Gewebe. Das Enzym Methämoglobin- pylori. Das Stickoxid schützt auch die Magen- reduktase verhindert den Anstieg der Me- wand, verbessert die Durchblutung der Ma- thämoglobinkonzentration über 1–2 % und genschleimhaut und verstärkt ihre Schleim- ermöglicht den Abbau von Methämoglobin. schutzschicht. Darüber hinaus erweitert das Die Aktivität dieses Enzyms ist jedoch bei Stickoxid die Blutgefässe und senkt dadurch Säuglingen unter 3–6 Monaten nicht voll- den Blutdruck (Weiss 2008). ständig ausgebildet. Außerdem ist bei ihnen die Methämoglobinbildung durch speziel- le Eigenschaften des fetalen Hämoglobins Nitrosamine erhöht. Deshalb reagieren Säuglinge auf die Das Nitrit bildet im Magen zusammen mit Methämoglobinbildung viel empfindlicher Aminen, Amiden und Aminosäuren Nitrosa- als Erwachsene (Nau et al. 2003). mine, die karzinogen sind. Nitrosamine sind Die Ursache für Methämoglobinämien bei aber auch im Rauch von Zigaretten und ande- Säuglingen war früher die hohe Nitratkon- ren Tabakprodukten enthalten. Die Bildung zentration in dem für die Zubereitung von dieser Verbindungen hängt vor allem von der Säuglingsnahrung verwendeten Trinkwasser Nitritkonzentration ab, der optimale pH-Wert in ländlichen Gebieten. Mit der Verbesserung liegt im Bereich von 3–4. Die Ascorbinsäure, der Trinkwasserqualität ist die Inzidenz die- das Vitamin E und sekundäre Pflanzenstof- ser Vergiftung bedeutend zurückgegangen. In fe, vor allem Polyphenole, verhindern diese seltenen Fällen wurde Methämoglobinämie Reaktion. Magenerkrankungen mit man- auch durch Brei aus nitratreichem Gemüse gelnder Salzsäuresekretion und bakterielle verursacht (Weiss 2008). Besiedelung des Magens fördern wiederum Die Methämoglobinämie und ihre klinis- die Nitrosaminbildung. Eine weitere Quelle chen Symptome (Zyanose, Blue baby) ent- für Nitrosamine endogener Herkunft bildet stehen dann, wenn die Blutkonzentration Stickstoffmonoxid. Deshalb steigt bei den mit 10–15 % übersteigt. Die Ursachen können einer erhöhten Bildung von Stickstoffmono- unterschiedlich sein: Genetische Defekte, xid verbundenen Erkrankungen die endogene Stoffe mit hohem Oxidationspotential (Chlo- Nitrosaminbildung (Kühne 2003, Dunkelberg rate, Perchlorate), aromatische Amine und et al. 2007). Eine genaue Einschätzung der aromatische Nitrosoverbindungen und Nit- endogenen Nitrosaminbildung ist nicht mög- rat. Erreicht der Methämoglobinspiegel im lich, weil diese von vielen Faktoren abhängt. Blut die Konzentration von 60–70 %, kann Die Schätzungen fallen sehr unterschiedlich die Krankheit infolge des Sauerstoffmangels aus und reichen von minimalen vernachläs- im Gewebe und in den Organen zum Tode sigbaren Mengen bis zu Mikrogrammwerten, führen. Wichtiger als die akute Toxizität von welche die Werte der exogenen Aufnahme

215 Miroslav Stransky eindeutig übersteigen (Kühne 2003, Dunkel- Kosmetika wird auf weniger als 0,05 µg/Tag berg et al. 2007). geschätzt (Marquardt und Schäfer 2004). Nit- Nitrosamine findet man in einer gan- rosamine aus Lebensmitteln werden im obe- zen Reihe von Lebensmitteln. Dazu gehören ren Teil des Dünndarms resorbiert, werden in vor allem gepökelte Fleischprodukte, Fisch, der Leber metabolisiert oder in unveränderter Gewürze, Käse und Bier. Nitrosamine sind Form über den Urin ausgeschieden. vor allem in Fleischerzeugnissen (Rohschin- Die seltene akute Intoxikation durch Nit- ken, gebratener Speck, gegrillte und gebra- rosamine führt zur Lebernekrose, eine Dosis tene Klobassen und Speckwürste) und in von 20–25 mg/kg Körpergewicht ist tödlich. Produkten enthalten, die im technologischen Viel grössere Bedeutung kommt der karzino- Prozess über 170 °C erhitzt werden (Ingr genen Wirkung der Nitrosamine zu, die sich 2008). Lebensmittel mit einem hohen Was- in der Leber, aber auch in anderen Organen sergehalt (Pizza, Toast Hawaii) enthalten (Dünndarm, Lunge) zu einer hoch karzino- nur eine geringe Menge an Nitrosaminen. genen Substanz umwandeln, welche die DNA Die Nitrosaminkonzentration in gepöckelten und RNA beschädigt (European Commission Produkten hat in den letzten Jahren deutlich 1997, Kühne 2003, Marquardt und Schäfer abgenommen. Während 1980 in der BRD 2004). Welche Dosis zur Bildung von Tumo- 12 µg/kg Nitrosamin nachgewiesen wurden, ren führt konnte bisher nicht geklärt werden. enthalten heute gepöckelte Produkte nur Das aktuelle Gesundheitsrisiko durch die Nit- 2,5 µg/kg (Weiss 2008). Der Grund dafür ist rosaminaufnahme über Lebensmittel wird als der niedrigere Nitritgehalt im Pökelsalz, der sehr gering gewertet (DGE 1996, Dunkelberg von 0,5–0,6 % bis auf 0,3 % zurückgegangen et al. 2007). ist. Das herkömmliche Räuchern mit heißem Das Ausmaß der Nitrosaminbildung aus Rauch wird durch künstliche Rauchpräparate Nitrat und Nitrit konnte bisher nicht bes- ersetzt und der Zusatz von Ascorbinsäure zu timmt werden, weil die Synthese durch viele der Pökelmischung inhibiert die Nitrosamin- fördernde oder hemmende Faktoren bedingt bildung. In gekochten Fleischprodukten sind ist. In epidemiologischen Studien wurde kein keine Nitrosamine nachweisbar (Ingr 2008, Zusammenhang zwischen der Höhe der Nit- Weiss 2008). rataufnahme und der Prävalenz von Tumo- Frischer Fisch kann bis zu 8 µg/kg Nit- rerkrankungen festgestellt (European Com- rat enthalten, bei geräuchertem Fisch ist der mission 1997, WHO 2003). Das Ausmaß der Gehalt niedriger. Gewürze, vor allem Pfeffer, Nitrosaminbildung ist bei hierzulande übli- können, bedingt durch den Trocknungspro- chen Ernährungsgewohnheiten wesentlich ge- zess, relativ hohe Nitrosaminkonzentrationen ringer als angenommen wurde. Das Gemüse – aufweisen. Beim Pfeffer werden Werte von bis die wichtigste Nitratquelle - verhindert durch zu 29 µg/kg Nitrat erreicht, bei Paprika 2 µg/ den Gehalt an Vitamin C und an Polypheno- kg (Dunkelberg et al. 2007). Käse enthält nur len die Nitrosaminbildung. Die Vorteile von selten Nitrosamine. Gemüse, das gesundheitsfördernde Substan- In den 70. Jahren galt das Bier mit Durch- zen enthält, überwiegen eindeutig über den schnittswerten von 2,7 µg/kg als eine wichtige höheren Nitratgehalt. Dazu trägt auch die Nitratquelle. Die Ursache dafür was die Reak- antimikrobielle Wirkung von Nitrat und sein tion der Amine aus Malz mit Stickoxiden aus Schutzeffekt auf die Magenschleimhaut bei. Luftstickstoff in den Trockenanlagen. Durch Deshalb wird auch in den Wintermonaten ein den Übergang zu geschlossenen Trockenan- Gemüsekonsum von 400 g/Tag empfohlen, lagen ist der Nitrosamingehalt in Bier bis auf davon 100–150 g in Form von frischen Sala- 0,1 µg/l deutlich zurückgegangen (Ingr 2008, ten (Classen et al. 2001, Diehl 2007). Weiss 2008). Der Organismus nimmt die Nitrosamine über den Verdauungstrakt, die Haut und die FAZIT Lunge auf. Die durchschnittliche Tagesauf- nahme über Lebensmittel wird auf 0,3 µg ge- Die Bedeutung der endogenen Nitrosamin- schätzt, bei 20 gerauchten Zigaretten erhöht bildung bei erhöhter Nitrataufnahme und sich die Aufnahme bis auf das Zwanzigfache dadurch auch das Risiko der Gesundheits- (17–85 µg). Die Nitrosaminaufnahme über gefährdung für die Verbraucher müssen auf-

216 Significance of nitrate, nitrite and nitrosamines in nutrition grund der wissenschaftlichen Erkenntnisse zu einer Methämoglobinemie führen, die sehr der letzten 20 Jahre neu bewertet werden. Die unwahrscheinlich ist, wenn die Ernährung- endogene Nitratbildung ist vergleichbar mit sempfehlungen für Säuglinge und die übli- der Menge, die mit der Nahrung aufgenom- chen Hygienemassnahmen eingehalten wer- men wird. den (Schmid 2006, Ingr 2008). Die Fleischprodukte machen nur einen Die Ergebnisse von epidemiologischen geringen Teil der Gesamtaufnahme von Ni- Studien belegen, dass ein hoher Gemüse- trat und Nitrit (10 %) aus. Zahlreiche wis- konsum vor vielen Tumorerkrankungen senschaftliche Studien weisen auf die po- und chronisch-degenerativen Krankheiten sitive Wirkung von Nitrat und Nitrit auf die schützt. Unter Berücksichtigung dieser Er- Gesundheit, im Einzelnen vor allem auf die kenntnisse darf festgehalten werden, dass das antimikrobielle Wirkung, den Schutz der Ma- Gesundheitsrisiko durch den Nitratgehalt in genschleimhaut und die Verbesserung der Gemüse im Vergleich zu seinen schützenden Blutzirkulation in der Magenschleimhaut Wirkungen gering ist und zwar auch unter hin. Es gibt keine epidemiologischen Beweise der Voraussetzung, dass der Gemüsekonsum für eine erhöhte Inzidenz und Prävalenz von in Zukunft deutlich steigt. Deshalb sollte wei- Tumorerkrankungen infolge der Nitrat- und terhin mindestens 5× täglich Gemüse (und Nitritaufnahme. Die allgemeine Warnung Obst) konsumiert werden und zwar unab- vor dem Konsum gepökelter Fleischprodukte hängig von der Jahreszeit. In vielen Ländern, ist aufgrund der heutigen wissenschaftlichen Tschechischen Republik eingeschlossen, sind Erkenntnisse unbegründet. Bei Neugebore- bereits entsprechende Interventionsprogram- nen kann eine unangemessene Nitritzufuhr me im Gange.

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1. AGES. Untersuchungen zum Nitratgehalt verschiedener Gemüsearten im Zeitraum 2003–2007a. Ne- publikováno [Unveröffentlicht]. 2. AGES: Untersuchungen zum Nitratgehalt tierischer Lebensmittel im Zeitraum 2003–2007b. Nepub- likováno [Unveröffentlicht]. 3. Classen HG et al. (2001). Toxikologisch-hygienische Beurteilung von Lebensmittelinhaltsstoffen und Zusatzstoffen. 2. Auflage. Behr’s Verlag Hamburg. 4. DGE (Hg) (1996). Ernährungsbericht 1996. DGE Frankfurt a. M. 142–146. 5. Diehl FD (2007). Chemie in Lebensmitteln. Wiley-VCH-Verlag, Weinheim. 6. Dunkelberg H, Gebel T, Hartwig A (2007). Handbuch der Lebensmitteltoxikologie. Wiley-VCH-Ver- lag, Wienheim. 7. Ebermann R, Elmadfa I (2008). Lehrbuch der Lebensmittelchemie und Ernährung. Springer Verlag Wien, New York, 573. 8. EFSA (2008). Opinion of the Scientific Panel on Contaminants in the Food Chain on a request from the European Commission to perform a scientific risk assessment on nitrate in vegetables. Journal. 689: 1–79. 9. Elmadfa I, Leitzmann C (2004). Ernährung des Menschen. 4. korrigierte und aktualisierte Auflage. Verlag Eugen Ulmer Stuttgart. 10. European Commission (Hg) (1997). Opinions of the Scientific Committee for Food on: Nitrates and Nitrite. Report of the Scientific Committee for Food (thirty-eighth series). Available at: http://ec.eu- ropa.eu/food/fs/sc/scf/reports/scf_reports_38.pdf 08 11. Hampel L, Zöllner H (2004). Zur Jodversorgung und Belastung mit strumigenen Noxen in Deut- schland. Ernährungs-Umschau 51: 132–137. 12. JECFA (1996). Nitrate. Toxicological evaluation of certain food additives and contaminants in food. WHO Food Additives Series No. 35. 13. JECFA (2002). Nitrate and nitrite. Evaluation of certain food additives. Fifty ninth report of the Joint FAO/WHO Expert Committee on Food Additives. WHO Technical Report Series Nr. 913.

217 Miroslav Stransky

14. Ingr I (2008). Nitrosaminy v masných výrobcích a dalších potravinách [Nitrosamine in Fleischerzeu- gnissen und weiteren Nahrungsmitteln ]. Nahrung und Lebensmittel. 76–78. 15. Kühne D (2003). Nitrat, Nitrit und Nitrosamine. Fleischwirtschaft 11: 143–147. 16. Marquardt H, Schäfer S (Hg) (2004). Lehrbuich der Toxikologie. 2. Auflage. Wissenschaftliche Ver- lagsgesellschaft Stuttgart. 17. Nau H, Steinberg P, Kietzmann M (2003). Lebensmitteltoxikologie – Rückstände und Kontaminan- ten: Risiken und Verbraucherschutz. Blackwell Verlag Berlin, Wien. 18. Rauscher-Gabernig E, Mischek D, Jessen C (2010). Nitrat in Lebensmitteln. Ernährung aktuell 2: 7–9. 19. Schmid A (2006). Einfluss von Nitrat und Nitrit aus Fleischerzeugnissen auf die Gesundheit des Menschen. Ernährungs-Umschau. 53: 490–495. 20. Trischler H (2006). Wie hoch sind die Nitratgehalte in Lebensmitteln? Available at: www.nitrat.eu/ ernaehrung.html 21. Verordnung (EG) Nr. 1881/2006. Available at: www.eur-lex.europa.eu/LexUriServ/LexUriServ.do?u- ri=Celex:32006R1881:DE:HTML 22. WHO (Hg) (2003). Nitrate (and potential endogenous formation of N-nitroso compounds). WHO Food Additives Series 50. Available at: http://www.inchem.org/documents/jecfa/jecmono/v50je06. htm 23. Weiss C (2008). Nitrat, Nitrit, Nitrosamine. Ernährungs Umschau. 55: 236–240.

 Contact: Miroslav Stransky, Frohburgstrasse 47 a, 8006 Zürich, Schweiz E-mail: [email protected]

218 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 219–228

ATTITUDE TO HEALTH IN MEMBERS OF THE MONGOLIAN MINORITY IN THE CZECH REPUBLIC

Valérie Tóthová1, Věra Veisová1, Helena Michálková1, Monika Jelečková1, 2

1University of South Bohemia, Faculty of Health and Social Studies, Department of Nursing, České Budějovice, Czech Republic 2Hospital Znojmo, Czech Republic

Submitted: 2011-07-18 Accepted: 2011-09-15 Published online: 2011-12-15

Abstract Health is a fundamental prerequisite for the quality of human life and ORIGINAL ARTICLE prosperity in general, as well as a condition for satisfaction of other needs. Health is important for everyone and we should all participate in its improvement. It is not only health workers who play an important role in activities directed towards keeping people healthy and improving their health condition; other specialists and political representatives should be engaged in this kind of activity as well. Personal participation and the responsibility of individuals for their own health are extremely important. The concepts related to the individual person’s care for their own health are valid not only for the majority part of the society but for all minority groups that live in the Czech Republic as well. One of the minorities that live either permanently or temporarily within our territory is the Mongolian minority. This article presents partial results of a research project that was focused on selected minority groups living in the Czech Republic. The research was done with support from the Internal Grant Agency of the Ministry of Health of the Czech Republic. The Mongolian minority group was one of eight minority groups that were included in this research project. One of the objectives of this research project was to find out about the attitude to health among the members of the Mongolian minority living in the Czech Republic. During our quantitative examination the data were collected by means of a questionnaire. The questionnaire consisted of a total of 140 items and – besides identification data – it comprised three parts. The items in the first part of the questionnaire were related to attitude to a person’s own health. The other parts of the questionnaire dealt with lifestyle, the specific needs and the satisfaction of the respondents with the health care in the Czech Republic. The collected data were processed using statistical methods. The set of respondents consisted of a total of 3,258 people from the eight most populous minorities in the Czech Republic. The set included members of the Romany, Ukrainian and Mongolian minorities, members of the Federation of Jewish Communities in the Czech Republic, Center of Muslim Communities, as well as the Diamond Way Buddhists (Karma Kagjü) and members of the Church of Jesus Christ of Latter Day Saints (Mormons). A total of 564 respondents were from the Mongolian minority. It is obvious from the results of the research that more than half of the respondents demonstrate a positive attitude towards their own health but it does not accord with the results related to activities that support health and with the results connected with their participation in preventive examinations and vaccination. The members of the Mongolian minority value their own

219 Valérie Tóthová, Věra Veisová, Helena Michálková, Monika Jelečková

health and they are aware of the importance of health in general, but preventive care is often underestimated. However, the respondents take their children to the doctor for preventive check-ups and they have them vaccinated.

Key words: attitude to health; preventive activities; Health 21 programme; Mongolian minority; alternative medicine

INTRODUCTION Office 2011). Mongolian migration to the Czech Republic has been based on a long- Health is a common value for everyone. lasting tradition of Czechoslovak-Mongolian Promotion of health is a process that helps relationships. The collaboration had been both individuals and communities to intensively developed since 1950. Mongolian influence the factors that may affect their citizens would come to our country for research health – thus improve their own health fellowships and short-term attachment, condition. Promotion of health pervades all while Czech students and employees were preventative stages. However, preventative welcomed in Mongolia as well. At the measures are not only related to health beginning of the nineties, the collaboration workers. It is important for citizens to play an was somewhat reduced. However, slowly active role in terms of preventative measures but surely, Mongolia is (again) becoming that are included in the primary prevention one of the priority countries within Czech whose task and aim is to prevent diseases international development cooperation. The (Strejčková 2007, Tóthová et al. 2010). The main reason for emigration from Mongolia is core programme that presents human health the current economic situation that affects the as a key priority for the countries within the life standard of the population – according European region is the long-term programme to official data, approximately half of the of the World Health Organization called Mongolian population lives on the limit of the “Health 21”. During the implementation of subsistence minimum (Kohn 2006). Living this trans-national programme within the conditions in many parts of the country government health policy it is necessary are very tough. The climate in Mongolia is to apply strategies that will influence the characterized by significant temperature determinants of the citizens’ health, regarding fluctuation. In addition, the soil in vast regions not only the health and economic aspects but is not suitable for farming and growing crops. the social and cultural aspects as well. Every A large part of the territory of Mongolia is culture has its own concepts of health, and covered with steppes with a harsh climate culture-related specific features are reflected where people live on nomadic pasturage in citizens’ attitude to health in general. This (Grollová and Zikmundová 2001). Therefore, fact should be reflected in the government Mongolia is a traditional migration country. health policy as well since, due to the social- However, Mongolians do not only migrate political changes at the end of the last for green pastures – they mainly migrate for century, the number of foreigners who live an easier life (often just a dreamed-of life) to in our country permanently or long-term is Mongolian cities and abroad, to find a job. continuously growing (Ivanová et al. 2005, This means that Mongolians come to our Farkašová et al. 2006). For this reason, very country to work in order to improve their often we get in contact with patients who are financial situation. Since it is difficult to get not from the Czech Republic and came from a an education in Mongolia, parents want to different cultural environment. These patients provide their children with education in include nationals of the Mongolian minority our country. Due to the growing Mongolian who have been living on the territory of the population in the Czech Republic, we meet Czech Republic temporarily or permanently. them in our medical institutions more often At present, according to the data provided than before. This minority originates from a by the Czech Statistical Office, there were in very different cultural background and, for total 5,167 Mongolians registered in the Czech this reason, from the point of view of trans- Republic as of 30 April 2011 (Czech Statistical cultural communication, we should pay a lot

220 Attitude to health in members of the Mongolian minority in the Czech Republic of attention to this minority. We should know norities in the Czech Republic, namely: their culture, customs and traditions better as the Romany, Ukrainian and Mongolian they may have a significant influence upon the minorities, followed by the members of behaviour of individuals if they are ill or if they the Federation of Jewish Communities in are admitted into a hospital. This minority the Czech Republic, the Center of Muslim group is one of eight minority groups that Communities, as well as the Diamond Way have been included in a research project that Buddhists (Karma Kagjü) and members of the is implemented thanks to financial support Church of Jesus Christ of Latter-Day Saints provided by the Internal Grant Agency of (Mormons). The members of the Mongolian the Czech Ministry of Health, “Provision of minority received 600 questionnaires in total, culturally-differentiated health care within of which 564 were returned. The Mongolian selected minorities in the Czech Republic”. minority research set consisted of 55% females and 45% males; 7% of the respondents were One of the objectives of the research up to 20 years of age; 40% were between 21 project was to elicit the attitude to health in and 30; 37% of the respondents were between members of the Mongolian minority in the 31 and 40; 13% were between 41 and 50; and Czech Republic. 3% of the respondents identified themselves as aged between 51 and 60. By the education level achieved, 31% of the respondents were MATERIAL AND METHODS university graduates, 21% higher education, 34% secondary education, 6% apprenticeship In the course of the first stage of the research qualifications and 8% basic education. In activities, an in-depth interview was held with terms of religious belief, 66% respondents representatives of the Mongolian minority. admitted Buddhism and 26% respondents During this inquiry, the current situation was claimed no religious belief. mapped in terms of their specific cultural needs in the context of the health care provided. It was important to establish contacts and find RESULTS out about the cultural and specific features and the lifestyle of the Mongolian minority. The attitude to one’s own health was examined The results from the interviews were through the response to the proposition “I statistically processed by means of descriptive take care of my health”. The respondents statistics. The results of the qualitative inquiry were able to express their posture within a obtained through the interview technique standardized scale with 5 options, see Graph were verified by means of an extensive inquiry 1. 75.61% respondents identified themselves via a questionnaire during the second stage with the statement fully or partially (sum of of the research (Tóthová et al. 2009). For answers “totally agree” and “rather agree”). the quantitative inquiry, the questionnaire On the other hand, disagreement (partial or method was applied. full) was manifested by 17.26% of respondents. The Questionnaire consisted of 140 items The remaining 7.13% were not able to take a in total. Besides identification data, the items specific stand and selected the option “I don’t were focused on the following areas: attitude know”. To sum up, it is obvious that most of to health, lifestyle, specific needs and the the members (3/4) of the Mongolian minority respondent’s satisfaction with the health care in the Czech Republic tend to take care of their in the Czech Republic. The Questionnaire was own health and they pay attention to it. translated into Mongolian. It was distributed Analyses following from the second sorting by a representative of the Mongolian minority, show a statistically significant difference in who cooperated with us. The data collection the attitude to one’s own health between the process ran from September to December Mongolian males and females living in the 2009. The data collected were processed Czech Republic. As regards the proposition by means of the SASD program (Statistic “I take care of my health”, full or partial Analysis of Social Data), version 1.4.4. agreement was expressed by 82.9% females The selected set included total 3,258 but only by 66.7% males. The chí quadrate respondents from the most populated mi- characteristics of independence (Χ2), in case

221 Valérie Tóthová, Věra Veisová, Helena Michálková, Monika Jelečková of differentiation by sex, equals to 22.505 on the other hand was not revealed. However, at 4 degrees of freedom. It means that the it is important to say that the application differences between Mongolian males and of the significance tests was limited due to females, as regards the attitude to their health, low or zero number of observations in some are statistically significant (applicable for the cells of the contingency tables developed. As significance level α=0.001) which leads to the for education, based on relative frequencies conclusion that the Mongolian females living we can only infer that respondents with a in the Czech Republic, according to their own university education express more effort statements, take care of their health more in terms of care of their own health, in than the Mongolian males. comparison with the respondents with lower A relation between the age and education education. on one hand, and the care of one’s own health

I totally agree

I rather agree

I don’t know

I would rather disagree

I totally disagree

Graph 1. “I take care of my health” (in %) N=564

18 16,63 15,9 16 14,2 14

12 10,44 10 9,1 8,5 8,5 7,89 8

6 4,73 4,13 4

2

0 ABCDEFGHIJ

Legend: A) reasonable food intake; B) keeping to principles of healthy nutrition; C) regular meals; D) sufficient fluid intake;E) sports activities; F) regular sleep; G) regular rest; H) participation in preventive check-ups; I) other activities; J) disregard of care for health.

Graph 2. What do you do to keep healthy? (in %) N=564

222 Attitude to health in members of the Mongolian minority in the Czech Republic

In response to the question “What do you 9.1% regular sleep, 4.13% rest regularly, 4.73% do to keep healthy?” 14.2% of answers were attend a general practitioner for preventive reasonable quantity of food, 16.63% were check-ups, 15.9% respondents claimed other keeping to principles of healthy nutrition, activities than the ones available in the 7.89% eat regularly, 8.5% drink the fluid questionnaire, and 8.5% of the respondents volume as recommended, 10.44% do sports, said that they did not take care of their health.

45 40 35 30 25 20 15 10 5 0 I would rather I totally I totally agree I rather agree I don't know disagree disagree

General practitioner 8,01 42,08 4,74 25,5 19,67 Dentist 6,04 35,66 4,72 23,58 30 Gynecologist (females) 13,53 37,4 2,39 17,51 29,18 Doctor-specialist 2,88 27,12 3,46 27,31 39,23

Graph 3. Regular preventative examinations (in %) N=564

By summing of relative frequencies of Republic – according to their own words – positive answers, in total 50.09% of the attend regular preventive check-ups at the respondents agree with the statement “I general practitioner more frequently than regularly attend preventive check-ups at the Mongolian males. general practitioner” while in total 45.17% of No connection was found between the respondents do not agree. Analysing the this feature and the age and the education results of the second level of the sorting, a of the respondents. Therefore, it is not statistically significant difference was found possible to insist that the attitude towards between Mongolian males and females living regular preventive check-ups at the general the Czech Republic as regards the attitude practitioner in the Mongolian minority living towards preventive check-ups at the general in the Czech Republic would differ depending practitioner. Full or partial agreement with on the age or the education of the respondent. the proposition “I regularly attend preventive In addition, a connection was identified check-ups at the general practitioner” was between this feature and the type of health expressed by 55.6% of females and only 43.3% insurance. However, in this case the strength of males. In case of differentiation by sex, chí of the test was weakened due to insufficient quadrate characteristics of independence test cases of observation in certain cells of the (Χ2) equals to 11.189 at 4 degrees of freedom. contingence table. Therefore, we only state It means that the differences between the that there is a trend that the respondents with Mongolian males and females in terms of public health insurance attend the general their attitude to regular preventive check-ups practitioner within regular preventive check- at the general practitioner are statistically ups more often than the respondents who do significant (this is valid for the significance not have any health insurance. This conclusion level α=0.05). It is possible to conclude that is very logical. the Mongolian females living in the Czech

223 Valérie Tóthová, Věra Veisová, Helena Michálková, Monika Jelečková

Fewer respondents agree with the The statement “I regularly attend pre- statement “I regularly attend preventive ventive check-ups at the gynaecologist” check-ups at the dentist”, in comparison with was presented only to females. By the sum the examinations at the general practitioner. of positive answers, in total 50.93% of the The sum of relative frequencies of positive females agreed and 46.69% of the females answers equals 41.7%; the sum of negative disagreed. 2.38% of the females answered answers is equal to 53.58% and 4.72% of “I don’t know”. Statistically important the respondents chose the answer “I don’t connections between this factor and the age know”. By simple comparison of the relative or the education were not identified; we can frequencies, it is obvious that the members only conclude that females without health of the Mongolian minority living in the Czech insurance tend to attend preventive check- Republic mostly disagree with the proposition ups of this type less than the females with on their regular preventive check-ups at the insurance. dentist, in other words, regular dentist’s care As regards the proposition “I regularly is not usual for most of them. Analysing the attend preventive check-ups at the specialist”, results of the second level of sorting, it was 30.00% of all respondents agreed while the found that the Mongolian females living in sum of negative answers was equal to 66.54%. the Czech Republic pay more attention to It means that a majority of the members of regular preventive check-ups at the dentist the Mongolian minority living in the Czech than Mongolian males. In this case, sorting Republic do not regularly consult – specialist by sex, the chí quadrate characteristics of the doctors. In terms of the sex, education or independence test (Χ2) is 19.586 at 4 degrees the age, there are no statistically significant of freedom. It means that the attitude towards connections related to the proposition “I regular preventive check-ups at the dentist regularly attend preventive check-ups at the depends on the sex of the respondent (this is specialist”. Analogically, in case of regular valid for the significance level α=0.001). There preventive check-ups, people without health is no significant connection between the age, insurance tend to visit specialists less than the education or the type of health insurance people who are insured. and the opinion on preventive checkups at the dentist.

Table 1. Preventative care of children (in %) – only the respondents who have children N=335

I totally I rather I don’t I rather I totally Propositions agree agree know disagree disagree I take care of my children’s health 31.94 53.13 4.48 5.67 4.78 I regularly attend preventive check-ups with my 18.81 32.24 5.38 25.38 18.20 children

As regards the proposition “I take care Out of the respondents who have children, of my children’s health”, 31.94% of the 53.08% allow their children to be regularly respondents totally agreed, 53.13% of the vaccinated, 31.06% do not allow their children respondents rather agreed, 5.67% rather to be regularly vaccinated; 15.86% of the disagreed and 4.78% totally disagreed. 4.48% respondents choose the vaccine themselves. of the respondents answered “I don’t know”. More than half of the respondents (59.48%) In terms of the proposition “I regularly attend go to the doctor as soon as possible if their preventive check-ups with my children”, children are ill; 37.63% wait some time to 18.81% of the respondents totally agreed, find out whether the illness dies down and, if 32.24 of the respondents rather agreed, not, they go to the doctor; and 2.89% of the 5.38% answered “I don’t know”, 25.38% of respondents tend to postpone a visit to the the respondents rather disagreed and 18.2% doctor as much as possible totally disagreed.

224 Attitude to health in members of the Mongolian minority in the Czech Republic

Table 2. Visit to the general practitioner with a child (in %)

Visit to the doctor – % Visit to the doctor – % regular vaccination in case of illness N = 309 N = 311 Yes 53.08 As soon as possible 59.48 No 31.06 Short delay – wait to see 37.63 whether the illness dies down Decision on the vaccine 15.86 Visit to the doctor 2.89 postponed as much as possible

Table 3. Visit to the general practitioner for adults (in %) N=564

Visit to the doctor – % Visit to the doctor – % regular vaccination in case of illness N = 311 Yes 14.36 As soon as possible 23.34 No 69.48 Short delay – wait to see 64.99 whether the illness dies down Decision on the vaccine 16.16 Visit to the doctor 11.67 postponed as much as possible

In response to the question of whether the doctor as soon as possible, 64.99% wait to they have regular vaccination done, 14.36% of find out whether the illness dies down and, if the respondents answered “Yes” and 69.48% not, they go to the doctor, while 11.67% of the answered “No”. 16.16% choose the vaccine respondents tend to postpone the visit to the themselves. In case of illness, approximately doctor as much as possible. one quarter of the respondents (23.34%) go to

50 47,06 45 40 35 29,02 30

25 21,57 18,82 20 16,47 15 10,2 10 7,84 3,53 5 0 ABCDEFGH

Legend: A) medicinal herbs; B) teas; C) natural medicine; D) massage; E) acupuncture; F) acupressure; G) homeopathic remedies; H) other. Graph 4. Preferred elements of alternative medicine (in %) N=255

225 Valérie Tóthová, Věra Veisová, Helena Michálková, Monika Jelečková

The question “Which elements of them chose the options connected with meals, alternative medicine do you prefer?” i.e. intake of nutrients is adequate, they follow was asked only to the respondents who the concepts of a healthy diet and eat regularly answered “Yes” to the closed question “Do (Graph 2). Eating habits of the members of the you prefer elements of alternative medicine Mongolian minority in the Czech Republic are to conventional medicine?”. It is obvious influenced by cultural customs and traditions from the results shown in the graph that which they brought with them from Mongolia. approximately half of the respondents prefer The Mongolian cuisine is characterized by a medicinal herbs. combination of meat and dairy products. The Mongolian cuisine depends on the seasons of the year. During the summer months, when DISCUSSION animals produce milk, the basic foodstuff is dairy products. In winter, meat prevails, The Health 21 programme declares that completed with flour and sometimes with one of the fundamental rights of every potatoes and rice. Mongolians mostly eat human being is the enjoyment of the highest mutton, but during recent years, due to attainable standard of health. Thereby, the opening of the markets, good restaurants WHO members affirm the dignity and worth which are operated by foreigners are able to of every person, and the equal rights, equal offer other kinds of meat as well (Kohn 2006). duties and shared responsibilities of all The traditional eating habits have been for health. Improvement of the health and obviously adjusted to Czech conditions. The well-being of people is the ultimate aim of mutton is mostly substituted with pork. social and economic development. Justice in In terms of the other options which we health is an important ethical and pragmatic offered in this item the results are rather category when creating health policy. Its low. As for the propositions “I take a rest fulfilment means that standard health care regularly” and “I attend preventive check- is provided equally and evenly for all social, ups”, the results do not achieve the level of ethnic, national, age and other segments of 5%. As for regular rest, the results confirm population. At the present time, there are no the high work engagement of the members big issues in this area but it is anticipated that of the Mongolian minority. The results we continuing social differentiation may bring have gained about attendance at preventive unfavourable consequences for the health check-ups do not agree with the results we of certain parts of the population (Health got in the following item, asking whether the 21 2001). In terms of the attitude towards respondents visit the general practitioner, foreigners, the Czech Republic, as a member the dentist, the gynaecologist (females) state of the European Union, applies the and specialist doctors. The results for this principles stipulated by the Council of Europe item are not satisfactory but they are much for integration of foreigners in the society higher (Graph 3). We can conclude that of the receiving country. The European the attitude to care for health, especially in integration policy accentuates the access to the field of prevention, is average or below health care; it declares that foreigners have average. Health is considered as a priority the right to health care of the same quality as but preventive care is often underestimated. the other citizens (Ivanová et al. 2005). A majority of the respondents do not attend Following from the results we have had, preventive check-ups and vaccinations and we can state that more than two thirds of the they postpone a visit to the doctor’s when respondents have a positive attitude to their they are ill (Table 3). These results agree with health or they care of their health (Graph 1). the results of the research done by Jelínková The concept of the responsibility for health, (2011), confirming that the members of the declared in the WHO documents, has been Mongolian minority tend to go to the doctor’s accepted. As regards the item where particular only if it is absolutely necessary. The attitude activities related to health were offered, we to the health of their children is different – did not get high values. Out of the options over half of the respondents take care of their which we offered in relation to respondents’ children’s health; they take them to preventive care of their health, more than one third of check-ups and have them vaccinated. If the

226 Attitude to health in members of the Mongolian minority in the Czech Republic children are ill, they take them to the doctor’s were taught these nearly forgotten methods as soon as possible (Tables 1 and 2). (Grollová and Zikmundová 2001). The environment of the Mongolian steppes is the place of origin of curative methods that shepherds shared for centuries. They were CONCLUSION different from western medicine and from the medical methods in the surrounding It is obvious from the results of the research countries as well – in the same way as the that more than half of the respondents have life of nomads differs from the settled life of a positive attitude to their own health, which farmers. Traditional Mongolian medicine does not accord with the results that are includes hundreds of medicaments of animal connected to activities which support health origin, dozens of salts and minerals, and a and to their participation in preventive check- great variety of curative herbs, trees and fruit ups and vaccination. They value health and products. Contemporary Mongolians tend are aware of the importance of health but to connect the traditional knowledge and preventive care is often underestimated. traditional curative procedures, wedded to However, the respondents take their children the lifestyle, diet and belief that they work, to preventive check-ups and have them with European medical science (Grollová vaccinated. The respondents prevent illnesses and Zikmundová 2001). The answer to and strengthen their health mainly through our question of whether the respondents their regimen. Approximately half of the prefer elements of alternative medicine respondents prefer elements of alternative was positive from approximately half of the medicine. To sum up, we can say that the respondents. This result does not correspond general rule stating that the interest in one’s to the information given in the literature own health varies is applicable in the members (Messner 2007). We assume that the result of the Mongolian minority as well. The attitude was influenced by the different environment of individuals to their own health is influenced in the country where the respondents live by the cultural particularity, as well as by the now as well as by their original locality in structure of the personality of the particular Mongolia – rural or urban environment. The person, by current needs, and by the value respondents whose answer to this question ladder. All these factors affect the behaviour was positive mostly use herbs and massage, of individuals in the area of preventative which is an inseparable part of traditional activities and keeping to recommended Mongolian medicine (Graph 4). Medicaments routines connected with their own health. and infusions in the traditional Mongolian The medical officers who work in the primary medicine are supplemented with methods of care should pay enough attention to members the so-called five axes. These methods do not of various minority groups. Through health demand much material. At the beginning of education, which is a very important method, the nineties the Institute of National Medicine they should influence their health-related began restoring the traditions of faith healing habits, lifestyle and behaviour to help them and doctors and nurses working in the field keep healthy.

The article is related to the solution of the grant project NS 9606-3, which is implemented with support from the IGA of the Ministry of Foreign Affairs of the Czech Republic.

REFERENCES

1. Český statistický úřad. Počet cizinců v ČR [Czech Statistics Office. Number of foreigners in the CR]. (online). (cit. 2011-07-09). Available at: http://www.czso.cz/csu/cizinci.nsf/ (Czech). 2. Farkašová D et al. (2006). Ošetřovatelství – teorie [Nursing - the theory]. Martin: Osveta, 211 p. (Czech). 3. Grollová I, Zikmundová V (2001). Mongolové. Pravnuci Čingischána [The Mongolians, Genghis Khan’s Great-Grandchildren]. Praha: Triton, 111 p. (Czech).

227 Valérie Tóthová, Věra Veisová, Helena Michálková, Monika Jelečková

4. Ivanová K et al. (2005). Multikulturní ošetřovatelství I. [Multicultural nursing I]. Praha: Grada Publishing, 248 p. (Czech). 5. Jelínková M. (2011). Vliv práce na zdraví migrantů – příslušníků mongolské menšiny v České republice [Influence of the Work upon the Health of Migrants – Members of the Mongolian Minority in the Czech Republic]. Kontakt. ZSF JU v Českých Budějovicích. XIII(2): 187–196 (Czech). 6. Kohn M (2006). Mongolsko [Mongolia]. Praha: Svojtka & Co., s. r. o., 324 p. (Czech). 7. Messner R (2007). Gobi. Poušť ve mně [Gobi. The Desert Inside Me]. Praha: Epocha, 207 p. (Czech). 8. Strejčková A (2007). Veřejné zdravotnictví a výchova ke zdraví [The Public Health System and Education for Health]. Praha: Fortuna (Czech). 9. Tóthová V, Rolantová L, Michálková, H, Nováková D (2009). K problematice zajištění kulturně diferencované ošetřovatelské péče ve vybraných minoritách v České republice [About the Problem Area of Provision of Culture-differentiated Health Care in Selected Minorities in the Czech Republic]. Kontakt. ZSF JU v Českých Budějovicích. XI(2): 282–291 (Czech). 10. Tóthová V et al. (2010). Zabezpečení efektivní ošetřovatelské péče o vietnamskou a čínskou minoritu [Provision of Effective Health Care for Vietnamese and Chinese Minorities]. Praha: Triton, 195 p. (Czech). 11. Zdraví 21 (2001). Osnova programu Zdraví pro všechny v evropském regionu Světové zdravotnické organizace [Health 21 (2001). The Outline of the WHO Programme “Health For All” in the European Region]. Praha: World Health Organization – Regional Office for Europe, Ministry of Health of the Czech Republic, 147 p. (Czech).

 Contact: Valérie Tóthová, Faculty of Health and Social Studies of the University of South Bohemia in České Budějovice, Department of Nursing, České Budějovice, Czech Republic E-mail: [email protected]

228 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 229–238

POSSIBILITIES OF USING THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF) BY GONIOMETRY AND MUSCLE TESTING IN PHYSIOTHERAPY

Zuzana Drábová1, Marek Zeman1, Miriam Ištoňová2, Ludmila Brůhová1

1University of South Bohemia, Faculty of Health and Social Studies, Department of Clinical and Praeclinical Branches, České Budějovice, Czech Republic 2University of Presov, Faculty of Health Care, Department of Physiotherapy, Slovak Republic ORIGINAL ARTICLE Submitted: 2011-08-02 Accepted: 2011-11-01 Published online: 2011-12-15

Abstract Introduction: International Classification of Functioning, Disability and Health (ICF) is the evaluation that has been elaborated by the World Health Organisation (WHO) and forms the conceptual frame for description of the disability. Today, relevant classification codes for persons with disability must be specified in the patient healthcare documentation in accordance with Communication No. 431/2009 Coll. (introduced into clinical practice in the Czech Republic by ICF starting from 1 July 2010). The objective of the article is to show or suggest, as appropriate, the options of assignment of ICF qualifier codes according to examinations performed in physiotherapy, specifically in goniometry and muscle test. Material and methods: Research was performed using the method of case study in Bertiny lázně Třeboň in 2011; the tested set consists of 3 respondents. Entrance and final examinations were performed using the given methods and ICF codes were assigned to the examination results according to suggested schemes. Results: For the sake of clear arrangement, the results were processed in a form of table schemes. As no similar thesis on this theme has been published yet, the only suggestion was to assign codes and their qualifiers to individual results of performed examinations, naturally supposing an ensuing broader discussion. Conclusion: In physiotherapy we use for examination various specific methods most of which are subjective ones. Still, we need to find a way to make the information obtained in the examination objective according to a uniform scheme. The ICF classification is a certain option offered to us. Transformation of results of specific examinations in physiotherapy into simple schemes of ICF qualifiers is undoubtedly very useful for the other members of the multidisciplinary team. The reason is that they subsequently have the possibility, on the basis of multidimensional assessment of the given individual’s condition, to understand at least a little or to be able to imagine the severity of determined examinations in an issue, which they alone do not understand.

Key words: ICF; physiotherapy; disability; qualifiers; goniometry; muscle test

229 Zuzana Drábová, Marek Zeman, Miriam Ištoňová, Ludmila Brůhová

INTRODUCTION degree of handicap (“body level outcomes”); emphasis is put also on evaluation of the level Several years ago, the abbreviation ICF of the capability to fulfil tasks and activities would have probably tell much to many of (“person level outcomes”) and the ability of the Czech physiotherapists, ergotherapists, participation in the environment, in which the doctors, students in healthcare and medical patient normally moves around (“social level subjects and others. Today, however, the monitoring”). Activities and participation situation is the opposite. From all quarters, form an important part of the assessment we can hear positive or negative responses process, but as a tradition they fail to be used to the classification which, according to the sufficiently in physiotherapy (Sykes 2008). Communication No. 431/2009 Coll., at the With regard to the fact that ICF has become beginning of June of the last year became the an integral part of rehabilitation, we can evaluation tool for measurement of disability assume that current tools for its evaluation on both individual and population levels. will be adapter in the future in order to be Although the World Health Organisation fully compatible with the encoding system approved ICF (International Classification of according to ICF (Stucki et al. 2002). Functioning, Disability and Health) as soon as Most examination methods used in in 2001, we seem until today to have problems physiotherapy focus on function of the in using and even generally understanding it locomotor system. These are specialised (Brunthansová et al. 2009). examinations of locomotor system evaluating Physiotherapy is a therapeutic procedure primarily the condition of the particular using various forms of energies (including system, neuromuscular system and soft the kinetic one) to influence pathological tissues (skin, fascia, etc.). conditions therapeutically (Stucki et al. 2007). In Chapter 7 regarding the body function It deals primarily with locomotor system, its component (b7), the ICF international analysis using specific diagnostic methods classification offers the possibility to encode and possibilities to influence it therapeutically neuromuscular functions and locomotion- (Kolář 2009). related functions (WHO 2008). The ICF international classification has We can find here the codes for functions undertaken to provide a universal language of joints and bones (b710-b729), codes to the rehabilitation disciplines covering for the functions of muscles (b730-b749) physiotherapy (Peterson and Rosenthal and codes for the function of locomotion 2005). With components of body fiction as such (b750-b799). ICF encodes also the and body structure, the classification really locomotion-related structures; these are reflects the basis of the physiotherapists´ contained in Chapter 7 regarding the body clinical practice (Allet et al. 2008). In clinical structure classification (s7). Here are the practice, we can use the ICF frame primarily to codes for the structures of head and neck area evaluate the condition and plan the therapy, to (s710), structures of shoulder area (s720), evaluate the outputs of therapy and to develop structures of upper limbs (s730), structures of the research (Stucki et al. 2003). pelvic area (s740), structures of lower limbs High-quality input evaluation is a basis (s750), structures of trunk (s760), and other of clinical practice, which can be used e.g. myoskeletar locomotion-related structures to plan the therapy or monitor changes (s770). (improvement or impairment of the condition, Apart from this, ICF classifies an as appropriate). With the growing healthcare individual’s mobility in Chapter 4 regarding demand, attention has been increasingly the components of activity and participation focused also on results and measurement (d4). Specifically, we can find here the codes of therapy results, respectively (Peterson et for changing and maintaining the posture al. 2010). With regard to the fact that ICF (d410-d429), for carrying, motion and encodes all aspects of human functioning, handling of items (d430-d449), for walking for complete evaluation of therapy outputs and moving (d450-d469), and/or codes for it necessary not only to determine the using transportation (d470-d499).

230 Possibilities of using the international classification of functioning, disability and health (ICF)

MATERIAL AND METHODS examinations, it is necessary to know the normal (physiological) scope of movement in The objective of the article is to show or the given joint. There is a significant allowance suggest, as appropriate, the options of for this scope, depending e.g. on quality of assignment of ICF qualifier codes according ligamentary system, which is conditioned to examinations performed in physiotherapy, both individually and, for instance, racially. specifically in goniometry and functional This may explain certain ambiguity in values muscle test. of the norm, which is reported by foreign Research was performed using the method literature as well. of case study in Bertiny lázně Třeboň in 2011; In Chapter b710, ICF describes functions the tested set consists of 3 respondents. of articular mobility, and the value of the Entrance and final examinations were assigned qualifier is subject to a single performed using goniometry and functional percental scale (0% for no problem – qualifier muscle test and ICF codes were assigned to the 0, up to 100% for complete problem – qualifier examination results according to suggested 4). So, if we wish to determine the disorder schemes. degree (or severity of the problem) according to ICF in an examination of ventral flexion in Goniometry shoulder joint (see Fig. 1), where the standard Using goniometric measurement on human is 90°, we will divide 90° into five groups body we determine either the angle, in which according to percental scope of qualifiers the joint is, or the angle which can be achieved (where 90° is qualified as no disorder and 0°, in the joint, whether through active or passive on the contrary, represents a one-hundred motion. Uniform measurement method is percent or complete disorder). Therefore, significant not only for the clinician, but also with shoulder joint flexion achieving 60° we for understanding among various experts can classify the scope of this motion with (Haladová and Nechvátalová 2008). When b7100.2 (medium disorder of mobility of one assigning qualifiers to results of goniometric joint).

Fig. 1. Visualisation of the possibility to assign qualifiers in classification of ventral flexion of the shoulder joint (Kolář 2009)

Examinations of the other joints may joint mobility according to ICF classification continue in a similar way. The following qualifiers in individual localisations used to table provides an overview of classification of examine the respondents.

231 Zuzana Drábová, Marek Zeman, Miriam Ištoňová, Ludmila Brůhová

Table 1. Overview of possibilities to assign qualifiers in classification of b7100 code (mobility of a single joint) in individual localisations according to degrees of range of movement in the joint

Qualifier and extent of degree in goniometry Localization 0 1 2 3 4 Hip flexion 90-86 85-68 67-46 45-5 4-0 Hip extension 15-14 13-11 10-8 7-2 1-0 Hip ext., int. rotation 45-43 42-34 33-23 22-3 2-0 Hip abduction 45-43 42-34 33-23 22-3 2-0 Hip adduction 30-28 27-23 22-16 15-2 1-0 Knee flexion 130-125 124-99 98-66 65-7 6-0 Ankle plantar flexion 50-48 47-38 37-26 25-3 2-0 Ankle dorsal flexion 15-14 13-11 10-8 7-2 1-0 Shoulder ventral flexion 90-86 85-68 67-46 45-5 4-0 Shoulder dorsal flexion 20-19 18-15 14-11 10-2 1-0 Shoulder ext., int. rotation 90-86 85-68 67-46 45-5 4-0 Shoulder abduction 90-86 85-68 67-46 45-5 4-0 Elbow flexion 140-135 134-106 105-71 70-7 6-0 Wrist palm., dors. flexion 90-86 85-68 67-46 45-5 4-0 Wrist radial duction 30-28 27-23 22-16 15-2 1-0 Wrist ulnar duction 45-43 42-34 33-23 22-3 2-0 Hand MP joint 90-86 85-69 68-46 45-5 4-0 Hand IP1 joint 120-115 114-91 90-61 60-6 5-0 Hand IP2 joint 90-86 85-68 67-46 45-5 4-0

Muscle test of normal muscle. The muscle reporting this Muscle tests inform about the strength of strength is able to make a movement in full individual muscles or muscle groups. The scope; still, it cannot overcome even such a strength scale has been modified for several small resistance which is represented by the times, but the one dating back to 1946 weight of the tested part of body. Degree 1 has remained the most widespread one. It (trace, T) – expresses preservation of approx. evaluates muscle strength in six degrees which, 10% of muscle strength. The muscle contracts at the same time, express their specification in in an attempt to make a movement, but its percents (Janda 2004). strength is not sufficient to move the tested Degree 5 (normal, N) – corresponds to part. Degree 0 – he muscle appear to report normal muscle or muscle with a very good no signs of contraction in an attempt to make function, as appropriate. Therefore, it is a movement. adequate to 100% of the normal. Degree 4 ICF classification evaluates the muscle (good, G) – corresponds approximately to strength functions in the same manner as 75% of strength of normal muscle. Degree 3 the functions of articular mobility, i.e. in five (fair, F) – expresses approx. 50% of strength of degrees. Unlike the muscle test, it does not normal muscle. The muscle reports this value differentiate between zero activity of muscle when it is able to make a movement in full and muscle jerk. Percental evaluation is not scope with overcoming the gravity, i.e. against identical, either. As Janda reports, however, the weight of the tested part of body. Degree 2 evaluation of muscle strength in percents is (poor, P) – identifies approx. 25% of strength disputable; at manual performance of tests

232 Possibilities of using the international classification of functioning, disability and health (ICF) it is substantially impossible to quantify it 4; therefore, the examination results have accurately, and therefore its character is been encoded so that qualifier 3 has been rather an orientational one (Janda 2004). assigned where the muscle was able to make Degrees 3, 4 and 5 of the muscle test are quite the movement with exclusion of gravity only compatible with qualifiers 2, 1 and 0. The (degree 2 according to muscle test). Degree 1 other three degrees of muscle test (0, 1 and 2) and 0 of muscle test were qualified as complete do not correspond with two qualifiers 3 and disorder, i.e. qualifier 4.

Fig. 2. Visualisation of the possibility to assign qualifiers in classification of muscle strength according to muscle test

RESULTS gonarthrosis, vertebrogenic algic syndrome of lumbar spine. He feels no difficulties in Respondent No. 1 – basic information: normal life; he has recovered swiftly from the A man, 67 years old, after implanted total operation of endoprosthesis, reports only pain endoprosthesis of hip joint on the right side, in lumbar spine with limited mobility of left coxarthrosis on the left side, both-sided lower limb.

Table 2. Overview of ICF qualifiers assigned in classification of code b7100 (mobility of a single joint) in individual localisations for respondent No. 1. Nrm. identifies an average physiological range of movement in the given joint, bold letters identify a change in qualifier values, X identifies the impossibility to measure the given angle in the joint in post-operation period.

Imput Output nrm. Goniometry ICF qualifier Goniometry ICF qualifier R L R L R L R L Hip flexion 90 90 78 0 1 90 83 0 1 Hip extension 15 10 8 2 2 12 10 1 2 Hip ext. rotation 45 X 30 X 2 X 30 X 2 Hip int. rotation 45 X 14 X 3 X 16 X 3 Hip abduction 45 43 26 0 2 45 32 0 2 Hip adduction 30 X 11 X 3 X 12 X 3 Knee flexion 130 105 96 1 2 110 105 1 1 Ankle plantar flexion 50 44 43 1 1 48 45 0 1 Ankle dorsal flexion 15 15 15 0 0 15 15 0 0

233 Zuzana Drábová, Marek Zeman, Miriam Ištoňová, Ludmila Brůhová

Table 3. Overview of ICF qualifiers assigned in classification of code b7300 (power of isolated muscles and muscle groups) in individual localisations for respondent No. 1. Nrm. identifies an average degree of muscle strength, bold letters identify a change in qualifier value, X identifies the impossibility to measure the given angle in the joint in post-operation period.

Imput Output nrm. Muscle test ICF qualifier Muscle test ICF qualifier R L R L R L R L Hip flexion 5 5 4 0 1 5 5 0 0 Hip extension 5 5 4 0 1 5 4 0 1 Hip ext. rotation 5 X 3 X 2 X 3 X 2 Hip int. rotation 5 X 3 X 2 X 3 X 2 Hip abduction 5 4 3 1 2 4 4 1 1 Hip adduction 5 X 3 X 2 X 3 X 2 Knee flexion 5 4 3 1 2 4 4 1 1 Ankle plantar flexion 5 5 5 0 0 5 5 0 0 Ankle dorsal flexion 5 5 5 0 0 5 5 0 0

Respondent No. 2 – basic information: hand, she suffered from pains); now she feels A woman, 71 years old, rheumatoid arthritis; good, suffers from no major difficulties, she the patient reports that her condition had suffers from pain (mostly in her right hand) been much worse before gold injection were from time to time. applied (she was unable to hold items in her

Table 4. Overview of ICF qualifiers assigned in classification of code b7100 (mobility of a single joint) in individual localisations for respondent No. 2. Nrm. identifies an average physiological range of movement in the given joint, bold letters identify a change in qualifier value.

Imput Output nrm. Goniometry ICF qualifier Goniometry ICF qualifier R L R L R L R L Shoulder ventral 90 90 90 0 0 90 90 0 0 flexion Shoulder dorsal flexion 20 30 30 0 0 30 30 0 0 Shoulder ext. rotation 90 72 83 1 1 76 85 1 1 Shoulder int. rotation 90 58 77 2 1 65 79 2 1 Shoulder abduction 90 68 69 0 0 70 70 0 0 Elbow flexion 140 135 138 0 0 137 138 0 0 Wrist palmar flexion 90 78 84 1 1 82 84 1 1 Wrist dorsal flexion 90 47 45 2 3 49 48 2 2 Wrist radial duction 30 17 19 2 2 18 21 2 2 Wrist ulnar duction 45 28 31 2 2 29 32 2 2 MP joint of 2. flexion 90 90 90 0 0 90 90 0 0 IP1 joint of 2. flexion 120 70 80 2 2 70 80 2 2 IP2 joint of 2. flexion 90 65 70 2 1 65 70 2 1

234 Possibilities of using the international classification of functioning, disability and health (ICF)

Table 5. Overview of ICF qualifiers assigned in classification of code b7300 (power of isolated muscles and muscle groups) in individual localisations for respondent No. 2. Nrm. identifies an average degree of muscle strength, bold letters identify a change in qualifier value.

Imput Output nrm. Muscle test ICF qualifier Muscle test ICF qualifier R L R L R L R L Shoulder ventral 5 5 5 0 0 5 5 0 0 flexion Shoulder dorsal flexion 5 4 4 1 1 4 4 1 1 Shoulder ext. rotation 5 4 4 1 1 4 5 1 0 Shoulder int. rotation 5 4 5 1 0 4 5 1 0 Shoulder abduction 5 4 4 1 1 4 5 1 0 Elbow flexion 5 5 5 0 0 5 5 0 0 Elbow extension 5 5 5 0 0 5 5 0 0 Elbow pronation 5 4 4 1 1 4 4 1 1 Elbow supination 5 4 4 1 1 4 4 1 1 Wrist palmar flexion 5 3 3 2 2 4 4 1 1 Wrist dorsal flexion 5 3 3 2 2 4 4 1 1 MP joint of 2. flexion 5 4 4 1 1 4 4 1 1 IP1 joint of 2. flexion 5 4 4 1 1 4 4 1 1 IP2 joint of 2. flexion 5 4 4 1 1 4 4 1 1

Respondent No. 3 – basic information: instability in standing position and during A man, 28 years old, condition after walk, he report blunt pain particularly in the complicated dislocation of the right hock; area of outer ankle after prolonged walk (still he perceives immobility of the right hock, wearing a fixateur).

Table 6. Overview of ICF qualifiers assigned in classification of code b7100 (mobility of a single joint) in individual localisations for respondent No. 3. Nrm. identifies an average physiological range of movement in the given joint, bold letters identify a change in qualifier value.

Imput Output nrm. Goniometry ICF qualifier Goniometry ICF qualifier R L R L R L R L Hip flexion 90 95 127 2 0 108 130 1 0 Hip extension 15 12 15 1 0 13 15 1 0 Hip ext. rotation 45 40 40 0 0 40 40 0 0 Hip int. rotation 45 34 39 1 0 38 39 0 0 Hip abduction 45 32 40 1 0 36 40 1 0 Hip adduction 30 35 43 1 0 40 45 1 0 Knee flexion 130 108 120 1 1 116 127 1 0 Ankle plantar flexion 50 5 48 3 0 11 48 3 0 Ankle dorsal flexion 15 5 15 3 0 8 15 2 0

235 Zuzana Drábová, Marek Zeman, Miriam Ištoňová, Ludmila Brůhová

Table 7. Overview of ICF qualifiers assigned in classification of code b7300 (power of isolated muscles and muscle groups) in individual localisations for respondent No. 3. Nrm. identifies an average degree of muscle strength, bold letters identify a change in qualifier value.

Imput Output nrm. Muscle test ICF qualifier Muscle test ICF qualifier R L R L R L R L Hip flexion 5 4 5 1 0 5 5 0 0 Hip extension 5 4 5 1 0 5 5 0 0 Hip ext. rotation 5 4 4 1 1 4 5 1 0 Hip int. rotation 5 4 4 1 1 4 5 1 0 Hip abduction 5 4 5 1 0 5 5 0 0 Hip adduction 5 4 5 1 0 5 5 0 0 Knee flexion 5 5 5 0 0 5 5 0 0 Knee extension 5 4 5 1 0 5 5 0 0 Ankle plantar flexion 5 2 5 3 0 3 5 2 0 Ankle dorsal flexion 5 2 5 3 0 3 5 2 0

DISCUSSION movement in individual joint according to ICF qualifiers may be another problem. The The presented article offers a certain proposal reason is that every movement in the joint for the method of assignment of qualifiers for has various scopes and, for instance, the classification of articular mobility (according subdivision of the scope of 130 degrees in to goniometric examination) and muscle knee joint flexion should be similar to that strength (according to muscle test). for the scope of 45 degrees of outer rotation Goniometric examination is complicated of the hip joint. This point certainly requires a primarily in method of identification of normal broader discussion. scope of movement in the joint. It is necessary Results of assignment of ICF classification to have regard to “structural synkinetic qualifiers to the given scope of movement movements” (typically e.g. in shoulder joint), according to suggested schemes for individual which change the scope of movement in the respondents have shown the following. In joint in a substantial manner. In case of the respondent No. 1, for instance, the scope above-mentioned shoulder joint, the average of flexion of his left knee joint improved physiological value of the scope of ventral significantly (from 96 to 105), which was flexion is 90° without synkinetic movement manifested by reduced qualifier value by one of the blade-bone, but already 180° with degree (see Table 2). Reduction of the qualifier this synkinetic movement (Haladová and value may subsequently be evaluated by other Nechvátalová 2008). Difference of results members of the multidisciplinary team as well of the examination remains to be another regardless of whether they do or do not have problem provided that an active movement is any knowledge of physiotherapy or testing by performed in the joint as compared with the means of goniometric examination. In final passive one. And last, but not least, there is consequence, the difference between the input the difference of the reported “normal” scopes and final examination, or the differing value in individual joints among various authors. of qualifiers is what matters. Final evaluation For instance, maximum scope of 45° is the of functional deficit of the given individual most commonly reported internal station in using other clinical examinations remains the hip joint, but according to Hoppenfeld it is question, however. 35° and according to Kapandji even 30° only. Transformation of muscle test results Providing for accuracy in decision-making into the value of ICF qualifiers has proved regarding the subdivision of the scope of to be much simpler than in the goniometric

236 Possibilities of using the international classification of functioning, disability and health (ICF) examination. In respondent No. 3, for are one of the basal examinations, which are instance, the muscle strength of both plantar used often and at most centres because they and dorsal flexion of the right hock improved provide basic information about the condition (from degree 2 to degree 3), which was of the locomotor system. manifested by reduced value of qualifier by one As no similar thesis on this theme has degree (see Table 7). There is an interesting been published yet, the only suggestion was to finding here that in the same patient the assign codes and their qualifiers to individual results of goniometric examination showed results of performed examinations, naturally an improvement in scope of movement into supposing an ensuing broader discussion. dorsal flexion only. This may be a valuable In goniometric examination we start from information for a clinician, which here serves physiological scope of movement in the joint, as an evidence of swifter improvement of the which we can measure. If the respondent function of muscle strength as compared to achieves the complete scope of movement, it function of mobility in the joint. is obvious that there is no disorder of articular mobility (qualifier 0). As to the values measured, we can easily recalculate the scopes CONCLUSION of qualifiers according to percental ICF scale, thus identifying the degree of disorder. Physiotherapy is applied in many disciplines The muscle strength scale according to of medicine and makes use of numerous Janda had to be adjusted for assignment of specific diagnostic procedures in order to qualifiers to the results of muscle tests. As identify pathological conditions (Kolář 2009). muscle tests evaluate muscle strength in For the greater part, however, these are six degrees and the ICF qualification in five subjective examinations, where experience degrees only, zero activity and muscle jerk of the physiotherapist and their approach to (degrees 0 and 1 according to muscle test) the given problem are literally what matters. were evaluated jointly by qualifier 4, the Still, we need to find a way to make the percental scope of which avers both degrees. information obtained in the examination It is natural that in order to identify the objective according to a uniform scheme. The adequate therapy we have to know not only ICF classification is a certain option offered the degree of disability of the function and to us. Transformation of results of specific structures (components b and s), but also examinations in physiotherapy into simple the capacity and performance of the given schemes of ICF qualifiers is undoubtedly individual (components d), all of this in very useful for the other members of the relation to the environment in which they multidisciplinary team. The reason is that they move around (components e). This thesis is subsequently have the possibility, on the basis an attempt to contribute to the discussion of multidimensional assessment of the given on methods of assessing disability using the individual’s condition, to understand at least ICF qualification. Specifically – to transform a little or to be able to imagine the severity of the outputs of certain existing examination determined examinations in an issue, which methods in physiotherapy into the values of they alone do not understand. ICF qualifiers so that these are understandable Two basic examination methods have and primarily usable for further processing in been used for the research, to wit goniometry terms of a multidisciplinary team. and muscle test according to Janda. These

REFERENCES

1. Allet L, Bürge E, Monnin D (2008). ICF: Clinical relevance for physiotherapy? A critical review. Advances in Physiotherapy. 10/3: 127–137. 2. Bruthansová D, Červenková A, Jeřábková V (2009). Nová klasifikace nemoci a zdraví [New classification of disease and health]. Česká geriatrická revue. 7/2: 90–96 (Czech).

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3. Haladová E, Nechvátalová L (2008). Vyšetřovací metody hybného systému [Examination methods for locomotor system]. Brno: Národní centrum ošetřovatelství a nelékařských oborů. 135 p. (Czech). 4. Janda (2004). Svalové funkční testy [Muscle function tests]. Praha: Grada. 328 p. (Czech). 5. Kolář P (2009). Rehabilitace v klinické praxi [Rehabilitation in clinical practice]. Praha: Galén. 713 p. (Czech). 6. Peterson DB, Rosenthal DR (2005). The International Classification of Functioning, Disability and Health (ICF) as an allegory for history and systems in rehabilitation education. Rehabilitation Education. 19/ 2: 75–80. 7. Peterson DB, Mpofu E, Oakland TD (2010). Concepts and models in disability, functioning, and health. In: Rehabilitation and health assessment: applying ICF guidelines. New York: Springer Publishing Company. 733 p. 8. Stucki G, Cieza A, Ewert T (2002). Application of the International Classification of Functioning, Disability and Health (ICF) in clinical practice. Disability and Rehabilitation. 24/10: 281–282. 9. Stucki G, Ewert T, Cieza A (2003). Value and application of the ICF in rehabilitation medicine. Disability and Rehabilitation. 25/3: 628–634. 10. Stucki G, Cieza A, Melvin J (2007). The international classification of functioning, disability and health: A unifying model for the conceptual description of the rehabilitation strategy. Journal of Rehabilitation Medicine. 39/4: 279–285. 11. Sykes C (2008). The International Classification of Functioning, Disability and Health: Relevance and applicability to physiotherapy. Advances in Physiotherapy. 10/3: 110–118. 12. WHO (2008). Mezinárodní klasifikace funkčních schopností, disability a zdraví [International classification of functional abilities, disability and health]. Praha: Grada. 280 p. (Czech).

 Contact: Marek Zeman, University of South Bohemia, Faculty of Health and Social Studies, Department of Clinical and Praeclinical Branches, České Budějovice, Czech Republic E-mail: [email protected]

238 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 239–254

THE ISSUE OF DIAGNOSTICS OF CHILDREN CEREBRAL PALSY IN RELATION TO PROVISION OF HEALTHCARE IN THE DISTRICT OF TEPLICE

Dana Šlechtová

Ústav zdravotnických studií UJEP, Ústí nad Labem, Czech Republic

Submitted: 2011-06-28 Accepted: 2011-11-08 Published online: 2011-12-15

Abstract Children cerebral palsy (CCP) is a chronic non-progressive disease ORIGINAL ARTICLE characterised by an disorder of locomotion and development of locomotion resulting from damage caused to the developing brain in prenatal, perinatal, and early postnatal period. The scope of motoric handicap and occurrence of associated deficits in the area of sensoric systems or in the areaof cognitive functions represents those factors that influence the individual’s life in all areas. From research in the area of provision of healthcare to a child with CCP from the point of holistic approach it has followed that the recommended procedure for general practitioners relating to CCP diagnostics and therapy is accepted in practice, but it completely fails to meet the present requirements from the point of early diagnostics. In practice, cooperation between the paediatrician and the specialist – children neurologist is close and functioning. The relation between identification of difficulties and the adequate reflex locomotion according to Vojta has followed from the research as well. The difference in time relations reported in the recommended CCP diagnostic and therapeutic standard of 1997 and the currently advocated requirements for early diagnostics of locomotion disorder is only stated in the given communication; the assessment and evaluation belongs only to expert paediatrists and neurologists dealing with the given issues. Further, a certain disagreement between the doctors and parents of the afflicted children has followed from the examination, especially in the area of providing the much needed information about condition and further development of the child.

Key words: children cerebral palsy; diagnostic and therapeutic standard; early diagnostics; physiotherapy; reflex locomotion method

INTRODUCTION complicated by sensoric disorders, epilepsy or mental retardation (Kraus CCP represents a complex of symptoms 2005, Miller et al. 2006). CCP represents covering numerous non-progressive, but permanent handicap, while the degree of frequently varying variants of motoric expression of individual symptoms may handicap in consequence of damage to the vary in time. immature brain in an early development CCP classification has undergone stage (Vágnerová et al. 2009). From the a complex development, which relates point of etiology, manifestations and closely to development of interest in severity of handicap, it is a heterogenic cerebral function disorders, to formation handicap and the condition is often of children neurology as an independent

239 Dana Šlechtová medical discipline and, last but not least, 2007, Marešová et al. 2011). It applies here to achievement of medicine in the area of quite clearly that the earlier is the CCP reduction of neonatal and infant mortality. development danger diagnosed, the earlier the Numerous classification schemes have treatment may begin and better results can be come into existence during the development. achieved. The thing at stake is the plasticity of Subdivision of CCP into 4 basic forms – spastic brain, which is the biggest immediately after form, dystonic-dyskinetic form, cerebellar the birth and decreases rapidly as the child form and mixed from – is regarded one of the grows older (Vojta 1993). simplest schemes. As Kraus states: “Recent Suspicion of CCP development danger CCP classifications do not refer to cerebellar may be pronounced in first weeks of life form again” (Kraus 2005, p. 84). Another already based on evaluation of postural classification scheme, the one with which the activity, postural reactibility by means working group Surveillance of Cerebral Palsy of position responses and evaluation of in Europe (SCPE) works, distinguishes three dynamics of primitive reflexes. Through main groups, the common sign of which is evaluation of a newborn child or infant in the abnormal posture and movement: spastic, above-mentioned manifestations it is possible atactic, dyskinetic form. SCPE represents a to capture deviations from psychomotoric network of cooperating CCP registers having development, identify the degree of central the aim to unify definitions, CCP evaluation coordination disorder, and indicate the criteria and further handling of the data for commencement of reflex locomotion therapy. monitoring and analysing the development of Early diagnostics of locomotion disorders individual CCP types in time. is based on the knowledge in neurophysiology Incidence of individual CCP forms and kinesiology regarding the postural differs in various studies available (Pharoah ontogenesis as a genetically determined et al. 1996, Cooley 2004, Panteliadis and program of an individual’s development Strassburg 2004, Miller 2007). As Kraus towards erected walking. The program takes (2005) reports, spastic diparesis (0.41– place automatically without teaching; it is 0.90/1000), hemiparetic form (0.55– activated in the neonatal period already. 0.79/1000) is the most frequently occurring Postural activity means spontaneous form of CCP in foreign studies. Occurrence of posture of the whole body and its movement dyskinetic form (0.16–0.21/1000) ranks on without external stimuli coming from the the third position, followed by quadriplegic examining person. By evaluating the postural form (0.07–0.16/1000) and atactic form activity, the examiner obtains basic general (0.11–0.15/1000). CCP profile varies in information about body posture and its time. In relation to the progress achieved by movement. Manifestations are evaluated in neonatology care, there is increasingly less the sense of manifestations adequate to the heavy form of CCP globally, but the number of development age or abnormal manifestations medium-heavy handicaps has been growing with presence of a deviation from standard. (Beckung et al. 2008). The number of athetoid As Marešová et al. (2011) emphasize, syndromes has decreased; on the other hand, however, knowledge of kinesiologic contents there are more and more diparetic forms of the child’s postural motoric development in relation to survival of heavily immature according to Vojta is substantial for accurate children. Generally, the number of children diagnostic evaluation. with CCP is held to be growing (Miller 2005). Postural reactibility presenting automatic Early capturing of the incident disorders control of body posture can be monitored and of locomotion, posture and deviations from evaluated starting from the neonatal age by psychomotoric development is substantial means of 7 positional reactions (Vojta 1993, and determining for the child’s development Kolářová and Hánová 2007). The examined as such (Vojta 1993, Kolář 2000, 2001). The child is exposed to provocation moves, i.e. key question is how early after the birth it is standard examination procedures defined as possible to recognize possible symptoms of to their contents and performance, to which CCP danger? Objectively, diagnostics of CCP the child’s CNS responses by regular standard development Langer is known to be possible response in a form of normal or abnormal within 3 months of age (Kolářová and Hánová movement patterns (Marešová et al. 2011).

240 The issue of diagnostics of children cerebral palsy

Abnormal responses are recallable in the • screening of psychomotoric development neonatal period already and can be used as of the child according to Vlach is performed a screening. It is well-known that 70% of the by general practitioner for children and population reports ideal models of postural the young (GPCY); reactivity at birth, 30% report deviations in • postural development screening according the number of abnormal positional reactions to Vojta in all at-risk children and children (Kolářová and Hánová 2007). The clinical unit with suspected delay in psychomotoric called central coordination disorder (CCD) development. This examination is comprises the newborns reporting abnormal recommended by GPCYs and repeatedly positional reactions and, according to number performed by children neurologists, of abnormal reactions, it is further subdivided paediatrists specialised in diagnostics of into 4 groups from very light to very heavy early locomotion disorders” (Komárek and form of CCD. Early therapy using the reflex Hadač 1997). locomotion method started as soon as in the As Severa reports: “Although Vlach’s neonatal period may result in normalisation of screening is used by both paediatrists and the condition or it may have significant effect children neurologists, it usually does not help on manifestations of cerebral paresis (Vojta capture CCP before the second half of the first 1993, Kolářová and Hánová 2007, Marešová years of the child’s age and often even later, et al. 2011). which is late already for the possibility of Further, evaluation of primitive reflexes achieving a very good effect – or even curing” and automatisms, which enables to reveal a (Marešová et al. 2011, p. 100). danger of motoric development disorder as The said screening according to soon as in neonatal period, is a part of early Vlach in CCP diagnostic and therapeutic diagnostics as well. In relation to diagnosis standard represents only an unbinding of CCP, primitive reflexology can be used recommendation. The question remains, to detect the spastic and dyskinetic forms however, whether it is realized in practice (Marešová et al. 2011). at all due to its extensiveness, and if it is Utilisation of early CCP diagnostics using not the case, according to which criteria the the primitive reflexology in modification paediatrist proceeds. Evaluation of primitive according to Vojta as well as the evaluation reflexology, postural reactibility, as described of postural reactibility requires not only strict above, requires considerable clinical standardisation of the examination procedure experience falling into the competence of a (stimulus), but also standardisation of children neurologist or neonatologist. the response to the given stimulus, which This thesis has not dealt with the question increases the demands not only on theoretical of diagnostics, but from the holistic point knowledge, but also practical experience of of view, early diagnostics are absolutely the diagnosing physician (Marešová et al. substantial for further development of the 2011). child and the diagnostics-related problems The first occasion to capture the deviations have only been outlined here. or commencing locomotion disorders is Monitoring and evaluation of offered upon utilisation of screening of the psychomotoric development falls into the postural development according to Vojta competences of a general practitioner for before release of the newborn child into children and the young, but parents play domestic environment. In subsequent period, a significant role in this important period diagnostics of the endangered child is in the for the child’s future development as well. hands of the general practitioner for children Parents should be aware of the potential and the young, who evaluates both the health for development of their child, and with condition and psychomotoric development this knowledge they should stimulate it within regular intervals during the first year adequately and watch closely. Monitoring of of its life (Kolář 2001). The CCP diagnostic all manifestations, reactions and behaviour of and therapeutic standard states the following the child is a precious source of information with regard to evaluation of psychomotoric for the doctor enabling him/her to evaluate development: “Early identification of the the child’s condition in general. In the event starting posture and movement disorders: of changes, deviations in psychomotoric

241 Dana Šlechtová development or any suspicion of CNS learn to work with the child, understand its affection, the paediatrist recommends, in manifestations, make sure that all its needs accordance with recommendations of CCP are satisfied while these may be signalled diagnostic and therapeutic standard, an in a different way as compared to a healthy examination by a children neurologist, in child (Vágnerová 2003). Another pitfall is the the competence of which is the screening of understanding and managing the therapy by postural development according to Vojta reflex locomotion. The paediatrist´s attitude and identifying the severity degree of the and “work with the parent of the afflicted central coordination disorder. During the child” is another substantial task in terms of subsequent period, repeated neurological provision of healthcare to a child patient with examinations, indicated auxiliary methods CCP diagnosis (Orth 2009). such as targeted metabolic screening, neurophysical examinations and imaging methods are performed, the task of which is MATERIAL AND METHODS to diagnose any other pathological conditions that induce a clinical picture similar to that Qualitative method of research was used which accompanies CCP. at work. For the initial data relating to Depending on identification of central identification of the healthcare level from the threat, which should be established no later point of view of healthcare staff in the given than the second month of life based on region, general practitioners for children early diagnostics, it is necessary to start the and the young were addressed using a rehabilitation treatment with Vojta’s method questionnaire investigating their opinion of of reflex locomotion (Kolář 2001, Zounková the level of healthcare provided to children 2005, Kolářová and Hánová 2007, Severa with CCP. 2009). Vojta has proved that by commencing The questionnaire contained 21 closed the rehabilitation before the fifth month of age questions. 5 closed questions offering it is possible to prevent from development of variants of answers were devoted to the issue light and medium-heavy spastic forms of CCP regarding the capturing of psychomotoric as well as athetosis; in the rest of children with development disorders. Paediatrists in Teplice the most heavy brain damage the heaviness of district were addressed in total number of 26 their handicap can be alleviated at least (Vojta general practitioners for children and the 1993). young. In subsequent phase of the research, Diagnostics are clearly the primary task structured interviews were conducted with of the doctors, whether it is the general the respondents – mothers of the children practitioner – paediatrist or children suffering from CCP. Inquiries regarding neurologist; the same attention, however, the establishing of diagnosis in their child should be devoted to the child’s parents were a part of semi-structured interview as as well. The period from recognition of well. The set consisted of 15 respondents. the first symptoms relating to disorders of Interviews with individual respondents were posture and movement up to establishing processed in case studies. The data obtained the final diagnosis represents the period of was categorised based on the general analysis. considerable psychic burden and uncertainty. Answers of paediatrists to the questions Parent require information, often they ask regarding early diagnostics were confronted repeatedly, not being able to absorb the in the discussion with recommendations of information being given at once, they look the diagnostic & therapeutic standard for CCP for psychic support in the contact with the and with the results obtained from structured doctor. Where CCP develops, the parent must interviews with the respondents of the face up to the child’s handicap, they have to observed set.

242 The issue of diagnostics of children cerebral palsy

RESULTS

Table 1. Capturing of locomotion disorders in time from the view of a general practitioner for children and the young

Alternative of answer 3rd month 6th month Numbers of answers 4 16

Table 1 presents an answer to the following young, 20 doctors responded. In this number question: “At which age, from the paediatrist’s 16 doctors reported – around the 6th month of point of view, is the locomotion disorder of a the child’s age, 4 doctors reported – around child captured the most frequently?”. the 3rd month of the child’s age. Out of the total number of 26 addressed general practitioners for children and the

Table 2. Capturing of locomotion disorders from the view of a general practitioner for children and the young

always a general practitioner for in most cases other specialist Alternative of answer children and the young Numbers of answers 4 16 0

Table 2 summarizes the paediatricians’ doctor, 16 doctors chose the alternative of the answers to the following question: “Who answer that – in most cases it is captured does capture the locomotion disorder most by a general practitioner for children and frequently?”. the young, none of the doctors chose the Out of the total number of 20 obtained alternative of answer that – the locomotion answers, 4 paediatricians chose the option disorder is captured by other specialist. The that – it is always captured by a primary care total number of obtained answers was 20.

Table 3. Capturing of the first locomotion disorders by the afflicted child’s parents from the view of a general practitioner for children and the young

Alternative of answer often occasionally in rare cases Numbers of answers 0 18 2

Table 3 shows the paediatricians’ answers Out of 20 answers obtained from general to the following question: “How often are the practitioners for children and the young, 18 parents alone the ones who points out the chose the alternative – occasionally, 2 doctors first signs of psychomotoric development chose the alternative – in rare cases only, disorders (i.e. they feel something is wrong none of the primary care paediatricians chose with the child s manifestations)?”. the alternative – often. The total number of obtained answers was 20.

Table 4. Procedure of the paediatrist when delayed psychomotoric development is identified

the child continues to the child is referred the child is referred Alternative of answer be monitored at the to the children to a specialized paediatrist´s office neurologist’s care consulting office Numbers of answers 7 15 2

243 Dana Šlechtová

Table 4 shows the answers to the following given question – the child is monitored at the question: “How does the doctor proceed when paediatrist’s office and the alternative – the he/she suspects a development locomotion child is referred to the children neurologist’s disorder?”. care, 1 doctor chose only the alternative – the Out of 20 returned completed ques- child is referred to the children neurologist’s tionnaires, 15 doctors refer the child to a care. Total occurrence of the chosen answers specialist – children neurologist, 7 doctors was 24. indicated the alternative – the child continues to be monitored at the general practitioner’s Results obtained from structured office. The alternative of answer – the child interviews with the respondents is referred to a specialized consulting office Categorised data obtained from case studies was used in 2 cases. Out of the total number of processed on the basis of structured interviews 20 doctors who answered the questionnaire, with respondents from the monitored set. 7 doctors chose 2 alternatives of answer to the

Table 5. Detection of the first manifestations relating to the handicap

R = respondent Sum R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 puerperium 7 1 1 1 1 1 1 1 3rd to 4th month 2 1 1 4th to 6th month 3 1 1 1 12th to 13th month 2 1 1 Total occurence 14 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Table 5 in categorised form presents category of answer – 3rd to 4th month was the respondents’ answers to the following represented 3 times in total. The category of question: “When did the first manifestations answer – 12th to 13th month was represented of the future handicap show from your point twice in total. of view?”. All the respondents answered in a single The most frequent category of answer – category. Respondent No. 12 did not answer during puerperium was represented 7 times the question, she adopted the child at the age in total. The category of answer – 3rd to 4th of 6. Total occurrence of categorised answers month was represented twice in total. The of the respondents is 14.

Table 6. Progress of establishing the diagnosis in time

R = respondent Sum R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 in 3rd month 2 1 1 in 6th month 5 1 1 1 1 1 in 9th month 1 1 in 12th month 4 1 1 1 1 more than 18 2 1 1 months Total occurrence 14 1 1 1 1 1 1 1 1 1 1 1 1 1 1

Table 6 in categorised form presents The most frequent category of answer – in the respondents’ answers to the following the period around the 6th month of age was question: “When was the diagnosis of children reported 5 times in total. The category of cerebral palsy established?”. answer – around the 12th month of age was

244 The issue of diagnostics of children cerebral palsy represented 4 times in total. The category of Respondent No. 12 did not answer the answer – around the 3rd month of age was question, she adopted the child at the age of 6 represented twice in total. The category of and the information of the above-mentioned answer – around the 9th month of age was character was not known to her. All the reported once. The category of answer – at respondents answered in a single category. more than 18 months of age was reported Total occurrence of categorised answers of the twice in total. respondents was 14.

Table 7. Awareness of parents in relation to the diagnosis

R = respondent Sum R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 Paediatrist – 8 1 1 1 1 1 1 1 1 insufficient info Paediatrist – 2 1 1 sufficient info Neurologist – 5 1 1 1 1 1 sufficient info Sufficient info – Motol, Lázně 6 1 1 1 1 1 1 Teplice Information from 5 1 1 1 1 1 other sources Info given by doctor not 1 1 understood Total occurrence 27 3 1 2 2 1 2 2 1 1 1 2 1 2 3 3

Table 7 in categorised form presents Respondents No. 2, 5, 8, 9, 10 and 12 the respondents’ answers to the following answered in a single category, i.e. once. question: “What was the awareness of the Respondents No. 3, 4, 6, 7, 11 and 13 answered parents regarding the diagnosis as provided in two categories of answers, i.e. twice in total. by the healthcare staff?”. Respondents No. 1, 14 and 15 answered in The most frequently reported category three categories of answers, i.e. three times of answer – information from general in total. Total occurrence of the categorised practitioner for children and the young answers was 27. was insufficient occurred 8 times in total. Category of answer – sufficient information Table 8 in categorised form presents provided at FN Motol, Lázně Teplice occurred the respondents’ answers to the following 6 times in total. Category of answer – question: “How satisfied you are with the care sufficient information from neurologist and attitude of the children neurologist?”. was reported 5 times in total. Category of The most frequently reported category answer – information from other sources – of answer – satisfied with the neurologist’s other parents, Internet was reported 5 times attitude was reported 7 times in total. in total. Category of answer – sufficient Category of answer – significantly satisfied information from general practitioner for with neurological care at FN Motol was children and the young was recorded twice reported 5 times in total. Category of answer – only. Category of answer – information dissatisfied with the neurologist’s attitude and obtained from other sources was reported the neurologist changed was reported 4 times 5 times in total. Category of answer – info in total. Category of answer – generally given by doctor not understood was reported satisfied – but more info and active interest once. of the doctor was reported once in total.

245 Dana Šlechtová

Respondents No. 1, 2, 3, 4, 5, 6, 8, 9, 15 answered twice in total in the categories. 10, 11, 12, 13 and 14 answered in a single Total occurrence of categorised answers of the category, i.e. once. Respondents No. 7 and respondents was 17.

Table 8. Satisfaction with the children neurologist’s attitude

R = respondent Sum R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 Satisfied with 7 1 1 1 1 1 1 1 attitude, info, care Satisfied with care, more info 1 1 and interest are missing Neurol. care at FN Motol – significant 5 1 1 1 1 1 satisfaction Dissatisfaction with attitude and 4 1 1 1 1 care – change of neurologist Total occurrence 17 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2

Table 9. Satisfaction with the attitude of the general practitioner for children and the young

R = respondent Sum R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 Satisfied with 2 1 1 attitude, info, care Satisfied with attitude, care, info 4 1 1 1 1 is missing The paediatrician is the family’s 1 1 support Dissatisfied with the information 3 1 1 1 provided Passive paediatrician – meets the parent’s 6 1 1 1 1 1 1 requests, but activity is missing Dissatisfaction with attitude and care – 4 1 1 1 1 change of doctor, disharmony Total occurrence 20 2 2 1 2 1 2 1 1 1 1 1 1 1 1 2

Table 9, in a categorised form, presents requests, but activity is missing was reported the respondents’ answers to the following 6 times in total. The category of answer – question: “What is your satisfaction with satisfied with attitude, care, but adequate the attitude of the general practitioner for info is missing was reported 4 times in total. children and the young?”. The category of answer – dissatisfaction with The most frequent category of answer – attitude and care – change of the general a passive paediatrist – meets the parent’s paediatric practitioner was reported 4 times

246 The issue of diagnostics of children cerebral palsy in total. The category of answer – dissatisfied Respondents No. 1, 2, 4, 6 and 15 answered with the information provided was captured twice in total in the categories. Respondents 3 times in total. The category of answer – No. 3, 5, 7, 8, 9, 10, 11, 12, 13 and 14 answered satisfied with attitude and information in a single category, i.e. once. Total occurrence provided was reported twice in total. The of categorised answers of the respondents was category of answer – the paediatrician is 20. clearly the family’s support was reported once only.

Table 10. Starting the rehabilitation therapy

R = respondent Sum R1 R2 R3 R4 R5 R6 R7 R8 R9 R10 R11 R12 R13 R14 R15 Spa health resort 1 1 Teplice Rehabilitation short stay hospital 6 1 1 1 1 1 1 Teplice Rehabilit. centre 3 1 1 1 Demosthenes Ústí Private rehabilitation 5 1 1 1 1 1 practice Rhb. therapy started before 3rd 4 1 1 1 1 month Rhb. therapy started from 3rd to 4 1 1 1 1 6th month Rhb. therapy started from 6th to 3 1 1 1 9th month Rhb. therapy started from 9th to 1 1 12th month Rhb. therapy started after 12th 3 1 1 1 month Total occurrence 30 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Table 10 in categorised form presents Categories of answers referring to the the respondents’ answers to the following facility, where the rehabilitation therapy question: “When and where was the took place, were distributed as follows: The rehabilitation therapy started?”. category of answer – Rehabilitation short The category of answer – rhb. therapy stay hospital Teplice was reported 6 times started before the 3rd month was reported in total. The category of answer – private 4 times in total. The category of answer – rhb. rehabilitation practice was presented therapy started from the 3rd to the 6th month 5 times in total. The category of answer – was reported 4 times in total. The category of rehabilitation centre Demosthenes in Ústí answer – rhb. therapy started from the 6th to nad Labem was reported 3 times in total. The the 9th month of life was reported 3 times in category of answer – Nové Lázně Teplice was total. The category of answer – rhb. therapy reported once. started from the 9th to the 12th month was All respondents answered in two categories reported once. The category of answer – rhb. of answers. The total number of categorised therapy started after the 12th month was answers was 30. reported 3 times in total.

247 Dana Šlechtová ------1 1 1 1 1 1 R15 ------1 1 1 1 1 1 R14 ------1 1 1 1 1 1 R13 ------R12 ------1 1 1 1 1 1 R11 ------1 1 1 1 1 R10 ------1 1 1 1 1 1 R9 ------1 1 1 1 1 1 R8 ------1 1 1 1 1 1 R7 ------1 1 1 1 1 1 R6 ------1 1 1 1 1 1 R5 ------1 1 1 1 1 R4 ------1 1 1 1 1 R3 ------1 1 1 1 1 1 R2 ------1 1 1 1 1 R1 7 14 1 12 14 6 14 2 8 14 6 1 14 8 5 3 7 12 2 total month th month rd No difficulties at the time Signs of locomotion disorders identified - before the 3 No difficulties, evaluated as at-risk newborn child Deliver of one faetus Difficulties identified in maternity hospital already Multiple delivery Delivery by section Natural delivery Delivery after term before the 6 Delivery at term Premature birth Categorised data Smooth course of pregnancy Problems in pregnancy already al al al al al o t o t o t o t o t t Identification of locomotion and posture disorders t – post-delivery period- puerperium t t psychomotoric development screening t – dellivery Diagnostic and therapeutic standard Early identification of at-risk children – pregnancy Table 11. Evaluation of categorised data provided by individual respondents in relation to diagnostic and therapeutic standard

248 The issue of diagnostics of children cerebral palsy ------1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 ------1 1 1 14 6 14 4 1 6 5 0 3 3 4 1 2 2 0 1 1 4 month th month month month month month month month rd th th th th th th month th to 6 to 9 month th rd th month of life month month of life month of life th th th rd identified before the month rd in care of neurologist since the 3 from 6 after the 12 after the 9 in care of neurologist since the 5 in care of children neurologist from birth in care after the 12 before the 6 in care of neurologist since the 10 in care of neurologist since the 9 from 3 before the 9 in care of neurologist since the 6 CCP 3 before the 9 of life Physiotherapy started before the 3

th th therapeutic of differential long-term al al o t o t postural development screening according to Vojta Establishing a definite dg and t Monitoring and evaluation by children neurologist t Establishing diagnosis before the 9 program before the 15 month month

249 Dana Šlechtová

Table 11 summarizes the occurrence of - - - 1 1

R15 categorised data in relation to diagnostic and therapeutic standard for CCP in 15 - - - - 1 1 respondents. The table presents only data R14 relating to early capture of psychomotoric development disorders with relevant area of - - - - 1 1 R13 the given standard. - - - - 1 1 R12 DISCUSSION - - - - - 1 R11 Early capturing of any disorders in posture, locomotion and deviations from - - - - - 1 R10 psychomotoric development is absolutely essential and crucial not only for establishing - - - - 1 1 R9 of a therapeutic plan, but also for a comprehensive approach to the individual - - - - 1 1 with CCP diagnosis. Recommended CCP – R8 diagnostic and therapeutic standard requires an early identification of at-risk children - - - - - 1 R7 already on the basic of history data related to the course of pregnancy, delivery, early - - - - - 1

R6 post-delivery period and subsequent objective examination of functional condition f the - - - - -

1 child by a paediatrist, children neurologist R5 before release into home environment. In this respect, the standard is valid and corresponds - - - 1 1 1 R4 with current requirements fro early capturing of posture and locomotion disorders according - - - 1 1 1

R3 to the evaluation. From the results obtained it followed that - - - - - out of the monitored set of 14 respondents (the 1 R2 15th respondent adopted the child at the age of 6), difficulties were identified as soon as in the - - - - 1 1 R1 maternity hospital in 6 children, one newborn child without difficulties was evaluated as an 7 0 22 29 15 2 1 1 at-risk one. Among these 7 newborn children, total there were 4 born prematurely, 2 newborns with history of smooth pregnancy, born by section at term, 1 newborn child with history of smooth pregnancy, born naturally at term.

month Subject to further evaluation of the th month month th th respondents’ answers it was found that out

to 12 of these 7 children, 6 were referred from the th maternity hospital directly into the care of combination of both methods reflex locomotion method according to Vojta Bobath concept after the 15 after the 12 Categorised data from 9 children neurologist (Table 11). As to the seventh child, it followed from the mother’s statement that discrepancies occurred between the place of delivery and the referring into the care of a general paediatric practitioner and neurologist in a different district. While monitoring the occurrence of al al the first difficulties relating to subsequent o t o t t t method of physiotherapy Diagnostic and therapeutic standard CCP manifestations, it was interesting to

250 The issue of diagnostics of children cerebral palsy monitor the time relations for other children reasons of time shift in referring the child to in the set (Table 11). In the 6th month, the specialist cannot be judged, the research symptoms relating to locomotion and posture examination was based on the respondents’ disorder manifested in another 3 children statements. In two cases the mothers reported (CCP diagnosed at later stage – two cases that they had notified the paediatrist of the of hemiparetic form and hypotonic form). development difficulties, repeatedly asking Occurrence of symptoms after the 9th month for additional examinations that subsequently was reported in the mothers’ responses in resulted in establishing the CCP diagnosis. In 4 cases (Table 9), while in 2 cases it was the one case difficulties showed as late as around mother who notified the general practitioner the 1st year of age in relation to walking; of discrepancies in the child’s development. subsequently, diparetic form of CCP was Both respondents were reassured by the confirmed at FM Motol, where the mother doctor that everything was OK and there was was referred to by the paediatrist. not reason to be worried. In relation to diagnostics, the respondents General practitioners for children and evaluated the satisfaction with provided the young, responding to the question information about the child’s conditions regarding the time capture of locomotion firstly from the primary care paediatrist, disorder, mostly chose the answer at the age and secondly from the specialist – children of 6 months. An answer at the age of three neurologist. months was recorded as well, which was in There is a certain discrepancy between 4 paediatrists out of 20 inquired ones (Table the parents and general practitioners for 1). All 20 paediatrists addressed agreed in the children and the young reflected in Table question of the first capture of locomotion and 9. In 4 cases, parents expressed their direct posture disorders; in most cases it is nobody dissatisfaction with the attitude and provided else than the general practitioner for children care, and in 6 cases the paediatrist is evaluated and the young or other specialist (Table 2). as a passive person fulfilling the parents’ From the point of respecting the requirements. A positive evaluation by recommended diagnostic and therapeutic parents was performed in 3 respondents only, standard in identification of locomotion which can be considered a serious problem and posture disorders, 10 children out of as in the healthcare system the paediatrist 14 were captured before the 6th month of provides care to a child up to the age of 18. age, while 6 children were referred to a From the position of general practitioners neurologist immediately after release from for children and the young, the evaluation in the maternity hospital; another 3 children respect of parents of the children with CCP were referred before the 3rd month of age and was more tolerant; in most cases, the parents the remaining child was referred at the age of were evaluated as being able to cope with and 5 months. Disorders in 4 children of our set provide care of their afflicted child. were diagnosed after the 9th month of life. It Cooperation and attitude of the specialist- should be noted that children suffering from children neurologist with the afflicted CCP in the given set were aged from 3 years to children’s parents was evaluated positively 17 years (CCP diagnosed after the 9th month of in most cases. Parents were provided age was reported in children, the current age adequate information; they were satisfied of whom is 7, 5, 8 and 15 years). with the specialist’s attitude as well. Only The relation between the general in 4 cases did the respondents express their practitioner for children and the young dissatisfaction with the information and and the specialist – children neurologist is provided care; they resolved the situation by regarded very important for early diagnostics finding other specialist. In 2 cases (Table 7), of development disorders (Kolář 2001). Out the respondents directly indicated that the of the monitored set, 6 children were referred information provided by the neurologist to the neurologist’s care after completion was insufficient. On the other hand, the of post-delivery hospitalisation, another 3 respondents in the interviews accentuated children in the 3rd month of life, the remaining the attitude and information provided at FN 4 children were referred to the care from the Motol, where they had been referred based 5th to the 12th month of age (Table 11). The on the neurologist’s recommendation, and

251 Dana Šlechtová further the information and attitude provided young and secondly from the data obtained by the staff at the children spa resort Nové from the interviews conducted with the Lázně in Teplice. mothers of children with CCP, the following Early diagnostics of locomotion disorders statement can be made: is necessary for commencement of an adequate 1. The relation between the general rehabilitation therapy (Table 10), which practitioner for children and the young is represented particularly by the therapy and the specialist – children neurologist of reflex locomotion according to Vojta. In is regarded very important for early this respect, the research has confirmed the identification of development disorders. respecting of the recommended standard; Out of the monitored set, 6 children in practice, efforts are made to start the were referred to the neurologist’s physiotherapy early. The therapy was started care after completion of post-delivery before the 6th month of the child’s age in hospitalisation, another 3 children in the 8 children of the monitored set (in 6 children 3rd month of life, the remaining 4 children it was started immediately after release from were referred to the care from the 5th to the the maternity hospital, in 2 children in was 12th month of age. during the 2nd month). In another 3 children, 2. Early commencement of physiotherapy it was started between the 6th and the 9th can be evaluated as a positive aspect month of life, in the remaining children it was in relation to recommendations of the around the 12th month. standard and particularly to requirements fro early diagnostics. Out of 14 children of the monitored set, an intensive CONCLUSION physiotherapy was started in 4 children immediately after release into home care The recommended CCP – diagnostic and after the birth and in another 4 children therapeutic standard processed by Komárek it was started between the 5th and the 6th and Hadač (2010) and approved by the month of age. Committee of the Czech Society for Children 3. Diagnostics of a threat to the child’s Neurology ČLS JEP on 5 March 1997 is still motoric development is fully in the doctor’s valid, but it contains provisions that already competence; parents, however, play a do not correspond fully with the requirements certain role in the period of learning about imposed on early diagnostics of locomotion and diagnosing the locomotion disorder. disorders. Monitoring of all manifestations, reactions Diagnostics based on evaluation of postural and behaviour of the child, keeping the activity, postural reactibility and evaluation primary care doctor informed about any of primitive reflexology enables to reveal the discrepancies or doubts on the parents’ danger of locomotion disorder as soon as in part is important not only for general the first 2 months of the child’s life. Early evaluation of the child’s condition, but it commencement of reflex locomotion therapy becomes also the basis for cooperation according to Vojta enables to achieve an between the parents and doctors. From adjustment of locomotion development in at- the questionnaire examination among risk newborns or infants reporting deviations the primary care paediatrists in the from psychomotoric development. In children given district it followed that the parents with cerebral paresis, early commenced address the paediatrist only “occasionally” therapy using the reflex locomotion influences with regard to any doubts regarding the the scope and heaviness of the handicap, appropriate and adequate locomotion contributing to reduction of occurrence of development of the child (Table 9). On the secondary changes of skeleton, reducing the respondents’ part, only 2 of them reported need of institutional care, and also influencing that they themselves notified the general the quality of life of both the child and the practitioner for children and the young whole family. of the discrepancies in psychomotoric On the basis of the obtained results, firstly development. from the questionnaire examination among 4. Although we live in times of an easy the general practitioners for children and the access to information, it is appropriate to

252 The issue of diagnostics of children cerebral palsy

continue providing the knowledge about of the afflicted child. For parents, psychomotoric development in the first communication and information are from year of life to the parents and guide them to the very beginning one of the substantial consistent awareness and understanding factors influencing not only the emotional of their own child’s manifestations. harmonisation, but also the subsequent 5. The investigation also confirmed the cooperation during the therapy and its generally valid importance of com- results, which is directly reflected in munication and professional attitude further life of the individual with CCP and of the healthcare staff to the children finding their position in the society.

REFERENCES

1. Beckung E, Hagberg G et al. (2008). Probability of Walking in Children with Cerebral palsy in Europe. Pediatrics. [online]. [cit. 2010-09-19]. Available at: 2. Cooley WC (2004). Providing a primary Care Medical Home for Children and Youth with CP. Pediatrics. [online]. [cit. 2010-10-18]. Available at: 3. Kolář P (2000). Posturální aktivita a DMO [Postural activity and CCP]. Zdravotnické noviny. Vol. 49, no 29, Suppl. Lékařské listy, p. 1–2 (Czech). 4. Kolář P (2001). Význam posturální aktivity pro včasný záchyt pacientů s dětskou mozkovou obrnou [Significance of postural activity for early capture of patients with children cerebral palsy]. Pediatrie pro praxi. Olomouc: Solen, s. r. o. 4: 190–194 (Czech). 5. Kolářová J, Hánová P (2007). Včasná diagnostika hybných poruch kojenců v prvním trimenonu prvního roku života [Early diagnostics of locomotion disorders of infants in the first trimenon of the first year of life]. Pediatrie pro praxi. 8(5): 264–267 (Czech). 6. Komárek V, Hadač J (1997). Doporučené postupy pro praktické lékaře – Dětská mozková obrna. Projekt MZ ČR zpracovaný ČLS JEP za podpory grantu IGA MZ ČR 5390-3 [Recommended procedures for general practitioners – Children cerebral palsy. Project of the Ministry of Health processed by ČLS JEP with support of IGA grant 5390-3 of the Ministry of Health of the Czech Republic]. Reg. č. o/101/218 [online]. [cit. 2010-02-10]. Available at: (Czech). 7. Kraus J (2005). Dětská mozková obrna [Children cerebral palsy]. 1st ed. Praha: Grada, p. 173–179 (Czech). 8. Marešová E, Joudová P, Severa S (2011). Dětská mozková obrna. Možnosti a hranice včasné diagnostiky a terapie [Children cerebral palsy. Possibilities and limits or early diagnostics and therapy]. Praha: Galén, 151 p. (Czech). 9. Miller F (2005). Cerebral Palsy. Springer Science+Business Media, LLC. New York NY 10013 USA. 1052 p. 10. Miller F (2007). Physical Therapy of Cerebral Palsy. Springer Science+Business Media. New York NY 10013 USA. 400 p. 11. Miller F, Bachrach S et al. (2006). Cerebral Palsy: a complete guide for caregiving. USA, Baltimore. The Jons Hopkins University Press. 473 p. 12. Orth H (2009). Dítě ve Vojtově terapii [A child in Vojta’s therapy]. Příručka pro praxi. České Budějovice: KOPP, 213 p. (Czech). 13. Panteliadis CHP, Strassburg HM (2004). Cerebral palsyprinciples and Management. New York. Thieme, 261 p. 14. Pharoah P, Platt MJ, Cooke T (1996). The changing epidemiology of Cerebral palsy. [online]. Archives of Disease in Childhood [cit. 2009-02-10]. Available at: 15. Severa S (2009). Časná diagnostika a terapie hybných poruch, zejména DMO, jako předpoklad úspěšné vertikalizace (vzpřímení) a lokomoce (pohybu) [Early diagnostics and therapy of locomotion disorders, particularly CCP, as precondition for successful verticalisation and locomotion]. [online]. [cit. 2010-02-10]. Available at: (Czech).

253 Dana Šlechtová

16. Vágnerová M (2003). Psychologie handicapu 3. část. Vývoj postiženého dítěte v předškolním věku [Psychology of handicap, Part 3. Development of an afflicted child at pre-school age]. Liberec: PF Technická univerzita Liberec, 27 p. (Czech). 17. Vágnerová M, Strnadová I, Krejčová L (2009). Náročné mateřství [Demanding maternity]. Praha: Univerzita Karlova, 309 p. (Czech). 18. Vojta V (1993). Mozkové hybné poruchy v kojeneckém věku [Cerebral locomotion disorders at infant age]. Praha: Grada, 361 p. (Czech). 19. Zounková I (2005). Fyzioterapie ve vývojové neurologii [Physiotherapy in development neurology]. Vox Pediatriae. Praha: Medix. 5(10): 20 (Czech).

 Contact: Dana Šlechtová, Ústav zdravotnických studií UJEP, Velká Hradební 13, Ústí nad Labem, Czech Republic E-mail: [email protected]; [email protected]

254 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 255–263

CHILD SUICIDE IN THE CZECH REPUBLIC FROM 2002– 2009

Dominika Průchová

University of South Bohemia, Faculty of Health and Social Studies, Social Work Institute, České Budějovice, Czech Republic

Submitted: 2011-09-23 Accepted: 2011-10-19 Published online: 2011-12-15

Abstract In recent years, the suicide rate among children and adolescents has been increasing. Seen over the long term, the overall suicide rate in the Czech ORIGINAL ARTICLE Republic has been decreasing since the 1970s, while during the last ten years we can see that the number of suicide cases among juveniles has been increasing. The epidemiology of suicidal behaviour is a significant indicator of the health condition of the population. There are numerous risk factors in terms of child suicide: demographic, family-related, cognitive, emotional, behavioural, and neurobiological, along with other factors such as the environment, psychiatric disease, aggression, impulsiveness or frustration. The aim of the research was to analyse the data related to child suicide in the age group from 0 to 18 years of age (according to the Convention on the Rights of the Child), to sort out the collected data by specific criteria, and statistically evaluate the relationships between the variables. The research method was secondary analysis of data obtained from the database of child suicide maintained by the Police of the Czech Republic, data available without informed consent. The subjects of the research were children aged 0 to 18 years. The research set comprised a total of 318 children from the Czech Republic, who committed suicide during the period 2002–2009. The data was statistically processed using the SPSS program, evaluated by means of the chi-quadrate test and Fisher’s exact test at the level p<0.05. In total, 237 boys (74.5%) and 81 girls (25.5%) committed suicide. The youngest child who committed suicide during the examined period was an eight-year-old boy. The number of suicide cases increases at the age of 13. Most children commit suicide at the age of 18, which is applicable for both genders. The research shows statistically significant dependence between certain variables.

Key words: child suicide; risk factors; the motive for suicide; the method of suicide

INTRODUCTION recommendations of the WHO, UNO and the Council of Europe to develop In 2008, the Czech government adopted a unified and complex strategy in this the “National Strategy for Preventing area of prevention. One of the aims of Violence against Children in the Czech the NAP is to analyse the preparation Republic 2008–2018”, which includes the of the data collection/monitoring, the “National Action Plan for Implementation implementation of the data collection of the Strategy for the period 2009– and monitoring, and research related to 2010” (the “NAP”), in order to fulfil the specific forms of violence. The first World

255 Dominika Průchová

Report on Violence against Children works Convention on the Rights of the Child), to with a definition of three forms of violence sort out the collected data by specific criteria, against children, one of which is violence and statistically evaluate the relationships against the self (suicidal behaviour and between the variables. intentional self-destructive behaviour) (WHO 2006, NAP 2008). In recent years there have been ever larger MATERIAL AND METHODS numbers of children and teenagers who try to resolve their problems through self harm In terms of the research of violence against (self-destructiveness and suicide). According children, we mostly paid attention to child to experts, the most frequent reasons are suicide. We cooperated with the Police of the dismal family relationships, divorce and Czech Republic, who provided us with the data parent quarrels. The Safety Line has published necessary for our secondary data analysis – a report on the type of problems that children data available without otherwise necessary had to face when they decided to call for informed consent. help. Self harm is one of the topics which As regards the area of child suicide, we have appeared in the conversation much obtained data from the Police of the Czech more often. Over the last two years, the total Republic (from the Regional Directorate) number of calls to the Safety Line increased for the period between 2002 and 2009 by 350% (Vodáčková et al. 2002, Safety Line from the whole Czech Republic (N=318). Association 2010). Data categories: gender, age, motive for There is a basic difference between suicide, method of suicide, place of suicide intentional self-harm and suicide. The child (i.e., region), ingestion of alcohol, drugs or who tries to commit suicide wants to end his medicaments before the suicide. or her life, while the child who inflicts self The data was saved in a special research harm wants to feel better (Kriegelová 2008). database, statistically evaluated, and Suicide is defined as: “Knowing and subsequently consulted with the participating intentional termination of one’s own life, when parties (Police of the Czech Republic) and with the person wishes to die and acts in order to a statistics expert. The data was statistically induce his or her death. If the person survives, processed using the SPSS program, evaluated the activity is qualified as an unsuccessful by means of the chi-quadrate test and Fisher’s suicidal attempt. The main goal of this activity exact test at the level p<0.05. is to die” (Veselý 2011). From the psychological point of view, Research method suicidal activities are ranked among disorders • Quantitative research – secondary data of self-preservation. It is a specific form of analysis aggression which is targeted against the Subject -matter of the research self. The risk of suicide can be increased by • Child suicide (completed self-destruction) various biological, psychological, health and Object of the research social factors. There are four forms of suicidal • Children aged 0–18 years (according to behaviour and suicidal activities: suicidal the Convention on the Rights of the Child) thoughts, suicidal tendencies, suicidal attempts, suicide (Koutek and Kocourková Data source: Police of the Czech Republic 2003, Machová et al. 2011, Veselý 2011). database Prevalence – trend – shows that the occurrence of suicidal attempts grows exponentially, depending on the age of the RESULTS child (Greening et al. 2010). The research set comprised 318 children, who The aim of the research was to analyse committed suicide during the period 2002– the data related to child suicide within the 2009. In total, there were 237 (74.5%) boys age group 0–18 years (according to the and 81 (25.5%) girls (Table 1).

256 Child suicide in the Czech Republic from 2002–2009

60

50

40

30

20

10

0 2002 2003 2004 2005 2006 2007 2008 2009 Source: Police of the Czech Republic Graph 1. Prevalence of suicide cases in the period between 2002 and 2009 (N=318) (in absolute numbers)

Graph 1 shows the prevalence of child Beginning in 2002, the annual number of suicide cases within the analysed period. cases slightly decreased.

Table 1. Number of child suicide cases by gender

Gender N % Table 1 shows that suicide is more pre- valent among boys. Three quarters of child Boys 237 74.5 suicide cases (74.5%) are by boys. Girls 81 25.5 Total 318 100.0 Source: Police of the Czech Republic

Table 2. Age of children at the time of suicide by gender (in absolute numbers)

Gender Age Total Boys Girls 8 1 0 1 9 1 0 1 11 2 0 2 12 4 0 4 13 10 1 11 14 12 7 19 15 22 14 36 16 38 16 54 17 55 17 72 18 92 26 118 Total 237 81 318 % 74.5 25.5 100 Source: Police of the Czech Republic

257 Dominika Průchová

The number of suicides increases with the commit suicide at the age of 18 among both age of the children (Table 2). The increase boys and girls – 118 total suicide cases. is obvious from the age of 13. Most children

Table 3. Motives for suicide (N=318)

MOTIVE for suicide N % conflicts and issues in the family 34 10.7 sex or relationship-related conflicts and issues 32 10.0 school-related conflicts and issues 20 6.3 sudden depression and psychological problems 62 19.4 mental disorder 13 4.1 existential conflicts and issues 8 2.5 physical disease 4 1.3 religious 2 0.6 fear of criminal prosecution 2 0.6 conflicts and issues related to work 1 0.3 other motive 17 5.3 motive not identified 124 3.9 Source: Police of the Czech Republic

The motive was identified in 194 (61%) family, relationship and school problems – in cases of child suicide. The most frequent total 86 cases (27%), see Table 3. motives were conflicts and issues in the

Table 4. Method of suicide by gender

Gender N=318 METHODS OF CHILD SUICIDE Boys Girls hanging, suffocation, strangulation 116 48.1% 19 23.8% jump from a height 27 11.8% 26 32.5% jump (lying) under a moving object 19 8.0% 10 12.5% jump out of a window 13 5.5% 7 8.8% drugs or medicaments 5 2.1% 11 13.8% shot from illegally held gun 14 5.9% 1 1.3% shot from legally held gun 14 5.9% 0 0 jump off a bridge 5 2.1% 4 5.0% gas poisoning 8 3.4% 0 0 other method 7 3.0% 0 0 burning 4 1.7% 0 0 deliberate crash 2 0.8% 0 0 poisoning toxins 1 0.4% 1 1.3% jump off a natural formation 1 0.4% 0 0 undercut 1 0.4% 0 0 drowning 0 0 1 1.3% explosive 1 0.4% 0 0 Total 237 100% 81 100% Source: Police of the Czech Republic

258 Child suicide in the Czech Republic from 2002–2009

The most frequently used methods of jumps from a window, jumps from a bridge or suicide were hanging, suffocation, stran- under a moving object – 65 boys and 47 girls gulation – 116 boys and 19 girls (43% of the (36% of the children) (Table 4). children), followed by jumps from a height,

Table 5. Methods of suicide by gender – statistical evaluation

METHODS OF SUICIDE jump from hanging, Gender drugs or a height shot from Total other method suffocation, medicaments or under a a gun strangulation moving object male 14 14 116 65 28 237 female 12 1 19 47 2 81 Total 26 15 135 112 30 318 male - o +++ – – – + female + o – – – +++ –

The variables were combined and legally or illegally). Girls commit suicide by subsequently processed statistically. It was jumping from a height or under a moving revealed that there is a highly statistically object, as well as by means of drugs or significant dependence between the gender medicaments (Table 5). As an instrument for and the method of suicide. Boys choose the statistical evaluation the Fisher’s exact hanging, suffocation and strangulation and test was applied, p<0.001. (less frequently) shooting with a gun (held

Table 6. Method of suicide by region – statistical evaluation

METHODS OF SUICIDE Place of hanging, jump from a suicide drugs or shot from other method suffocation, height or under (region) medicaments a gun strangulation a moving object Prague o o – – +++ o South Bohemia o o + o o South Moravia o o o o o North Bohemia o o o o o Moravia-Silesia o o o o o Central o o o o + Bohemia East Bohemia o o o o o West Bohemia o o o o o

There is a highly statistically significant hanging, suffocation or strangulation; and in dependence between the method of suicide Central Bohemia the most frequently used and the place of suicide, i.e., the region in method of suicide is shooting from a gun (held the Czech Republic (Table 6). In Prague, legally or illegally). At this point, no statistical children most frequently commit suicide by significance was found among other regions jumping from a height or under a moving in the Czech Republic. For the purposes of object – highly statistically significant. In the statistical evaluation the chi-quadrate test South Bohemia, children commit suicide by was applied, p=0.045.

259 Dominika Průchová

Table 7a. Ingestion of medicaments before suicide by gender – statistical evaluation

MEDICAMENTS Total Gender yes no male – – – +++ female +++ – – – 318

The statistical evaluation was applied of statistical evaluation the chi-quadrate test for other circumstances in connection with was applied, p<0.001 (Table 7a). Another the child suicide cases, such as ingestion of highly statistically significant dependence was medicaments before the action and ingestion found between age and ingestion of alcohol of alcohol before the action. There is a highly before suicide. In the age group of 16–18 statistically significant dependence between years it was proven that children use alcohol gender and ingestion of medicaments before before suicide. For the purposes of statistical suicide. Girls use medicaments before they evaluation the chi-quadrate test was applied, commit suicide, boys do not. For the purposes p<0.001 (Table 7b).

Table 7b. Ingestion of alcohol before suicide, by age groups of children – statistical evaluation

ALCOHOL Total Age yes no 8–15 – – – +++ 16–18 +++ – – – 318

DISCUSSION (25.5%) girls (Table 1). It is clear from Table 1 that in our research set suicide is much more The aim of the research was to analyse prevalent among boys. Veselý and Vágnerová the data related to child suicide in the age also emphasise the gender differences in this group of 0–18 years. The data necessary problem area. The difference is based on the for the secondary analysis was obtained in fact that boys are bolder than girls in terms cooperation with the Police of the Czech of committing the action. Attempted suicide is Republic, for the period of 2002–2009 from more prevalent among girls, while boys more the whole Czech Republic (N=318). The often complete the suicide (Vágnerová 2005, following variables were evaluated: gender, Veselý 2011). age, motive of suicide, method of suicide, Graph 1 shows the prevalence of child place of suicide – region, ingestion of alcohol, suicide during the examined period. drugs or medicaments before the suicide. The Compared to 2002, the annual number of data was saved in a special research database child suicide cases is decreasing slightly. The and was statistically evaluated. number of suicides was lowest in 2007. The obtained data was processed by means Table 2 indicates that most child suicides of descriptive statistics and subsequently are committed at the age of 18, which is the tested by means of statistical tests, the chi- same in both genders – in total 118 suicide quadrate test and the Fisher’s exact test, and cases. The number of suicide cases increases the relationship between the variables was as the children get older. There is a significant evaluated at the level p<0.05. increase from the age of 13, in total 11 The research set comprised 318 children, children; then total 19 children at the age of who committed suicide from 2002–2009. 14, 36 children at the age of 15, 54 children at In total, there were 237 (74.5%) boys and 81 the age of 16, and 72 children at the age of 17.

260 Child suicide in the Czech Republic from 2002–2009

The prevalence of suicide attempts increases shooting with a gun (held legally or illegally), exponentially with the age of children, which drugs or medicaments (gas poisoning and is stated in research papers from the United poisoning toxins), other method (burning, States and Africa (Greening et al. 2010) and crash, drowning, undercut, explosive). A was confirmed by our research as well. highly statistically significant dependence The motive was identified in 194 cases was found between gender and the method (61%) of child suicide. In 124 cases (39%) of suicide. Fisher’s exact test, p<0.001, was the motive was not found. The most frequent applied for the statistical evaluation. Boys motives of child suicide were conflicts and commit suicide by hanging, suffocation or issues in the family, followed by relationship strangulation (48.1%) and (less frequently) by and school issues in 86 cases (27%), see shooting with a gun (held legally or illegally) Table 3. The other important motives for (11.8%). Girls commit suicide by jumping child suicide are sudden depression and from a height (32.5%) or under a moving psychological problems in 62 cases (19.4%) object (12.5%), and by means of drugs or and mental disorder in 13 cases (4.1%), medicaments (13.8%) (Table 5). According schizophrenia, bipolar disorder (formerly to Veselý and Vágnerová, boys tend to prefer called manic depressive insanity), as well as the “hard way”, i.e., hanging, shooting or delusions and other similar disorders, and jumping, while girls opt for a „softer“ style, psychological problems – affective disorders, i.e., poisoning. Therefore, the suicide attempt phobias, anxiety, eating disorders and is more often reversible by a rescue action in depression. Children are strongly influenced girls than in boys. Our research confirms these by social and environmental factors, such conclusions, but our conclusion is different as interactions required in daily life with in the case of jumps from a height or under internalized family rules, values and norms, a moving object. According to our analysis, followed by the emotional climate in the suicide by jumping is more frequent in girls family, excessive criticism towards the than in boys (Vágnerová 2005, Veselý 2011). child, and traumatic events in the life of the It is obvious from Table 6 that there is a child, which develop feelings of fear and highly significant dependence between the hopelessness. Another significant aspect method of suicide and the place of suicide, i.e., is exposure to deliberate self-destructive the region in the Czech Republic. In Prague, behaviour, i.e., association between the origin children most frequently commit suicide by of deliberate self-destructive behaviour and jumping from a height or under a moving suicidal behaviour and previous exposure object – highly statistically significant. In to deliberate self-destruction or suicide South Bohemia, children commit suicide in the child’s surroundings. This emerges by hanging, suffocation or strangulation. In mainly during early adolescence. At present, Central Bohemia the most frequently used the most frequent way in which vicarious method of suicide is shooting with a weapon self-destructive behaviour is introduced is (held legally or illegally). No statistical through sharing detailed information and significance was found among other regions descriptions of self-destructive activities on in the Czech Republic. For the purposes of the internet – the “copy-cat effect” (Benešová the statistical evaluation, the chi-quadrate 2008, Kriegelová 2008, Svoboda et al. 2009). test was applied, p=0.045. It was not possible Table 4 shows that the most frequent to statistically evaluate the numbers of child methods of child suicide were hanging, suicide cases in specific regions of the Czech suffocation and strangulation – 116 boys Republic. Therefore, a more detailed analysis and 19 girls (43% of the children), followed is necessary. by jumps from a height, a window, a bridge The method of statistical evaluation or under a moving object – 65 boys and was applied on other circumstances related 47 girls (36% of the children). The variables to child suicide, such as ingestion of were combined and statistically tested in medicaments before the suicide and ingestion the following groups: hanging, suffocation of alcohol before the suicide. There is a highly and strangulation (no combination), a jump statistically significant dependence between from a height and under a moving object gender and the medicaments ingested before (jump off a window, jump off a bridge), the suicide. Girls use medicaments before they

261 Dominika Průchová commit suicide, boys do not. For the purposes relationships and weak results at school. of the statistical evaluation, the chi-quadrate Children sometimes magnify the potential test was applied, p<0.001 (Table 7a). Another punishment at home and decide to solve the highly statistically significant dependence problem definitively. Among schoolchildren, was found between age and the ingestion of this kind of hazard is extremely dangerous. alcohol before suicide. In the age group of At this age, children have not developed 16–18 years it was proven that children use the feeling of their own mortality yet. Every alcohol before suicide. For the purposes of the mention of potential suicide from any statistical evaluation, the Fisher’s exact test child must be taken seriously, as children was applied, p<0.001 (Table 7b). underestimate the final effect of suicide. Foreign research studies present other Mainly in children, but in adolescents as well, conclusions as well. In our follow-up work, it is possible to apply various forms of therapy, we would like to focus on them through in particular non-verbal psychotherapeutical child casuistic reasoning and to cooperate approaches, such as therapy through games with experts in the field of pedopsychiatry. or art therapy. Drawings may reveal issues According to the research papers, over which would stay hidden during interviews. In 18% of children aged 8 to 18 say that they addition, while working with suicidal children have suicidal thoughts, and among many and adolescents, music therapy or relaxation adolescents who committed suicide, suicidal techniques can be applied (Svoboda et al. behaviour appeared earlier, in the childhood. 2009, Veselý 2011). This study focussed on parenting styles and It follows from our research that there is their influence on suicidal behaviour and a statistically significant dependence between conduct among children. It was concluded gender and the method of suicide, between that a parental (foster) environment that the method of suicide and the place of suicide lacks sensitivity and is overly strict and (regions in the Czech Republic), between the full of animosity is often the cause of gender and the ingestion of medicaments suicidal behaviour. The risk factors include before the suicide, as well as between age and depression, aggressiveness, the environment, the ingestion of alcohol before the suicide. family – mainly the parenting styles in the No statistically significant dependence was family (Greening et al. 2010). proven between the other factors. The source The WHO’s study, “Health Behaviour in of the data was the database obtained from the School-aged Children 2005/2006 (HBSC)” Police of the Czech Republic in cooperation presents some of its outputs in terms of child with the Regional Directorate for the South suicide: girls admitted that they had feelings Bohemian Region. of depression more often than boys aged Prevention is a crucial part of child 13 to 15, as well as suicidal thoughts before psychology and psychiatry. The aim of the age of 15. Good communication with prevention is the effort to reduce the parents reduces the probability of suicidal occurrence of suicidal behaviour. Primary thoughts in all age groups. Adolescents who prevention is focused on decreasing the are happy with their family relationships occurrence of suicidal behaviour and conduct suffer from depression and suicidal thoughts among children, as well as on identification less than their peers. The best environment and elimination of risk factors. Secondary for adolescents is a family with their natural prevention is focused on timely identification parents. According to the WHO’s study and treatment of clinical symptoms, including (Samm et al. 2010), suicidal thoughts were crisis intervention. Tertiary prevention is more prevalent among adolescents from then focused on mitigating the consequences incomplete families with a step parent than in of clinical disorders in order to avoid their families with a single parent. repeated occurrence. Children are exposed to risk and protective factors. The risk factors increase the child’s vulnerability, while the CONCLUSION protective factors mean a positive influence on the child. The protective factors include, Hopelessness in children appears mainly in for example, the child’s positive temperament, connection with family relationships, peer as well as the intelligence, physical health,

262 Child suicide in the Czech Republic from 2002–2009 physical fitness, social skills, harmonious aim of prevention is to lessen the risk factors, family life, proper parenting, support from thereby strengthening the protective factors parents, good emotional climate in the family, on the side of the child, the family and the quality of social environment (good schools, environment (Vodáčková et al. 2002, Koutek extracurricular activities, crisis centres). The and Kocourková 2003, Vágnerová 2005).

The article was written under the auspices of the GAJU 071/2010/S project, with the title “Prevention of Accidents and Violence in Children Age”.

REFERENCES

1. Benešová V (2008). Suicidální jednání dětí a mládeže [Suicidal Action in Children and Young People]. Prevence úrazů, otrav a násilí. 4(2): 123–130 (Czech). 2. Greening L, Stoppelbein L, Luebbe A (2010). The Moderating Effects of Parenting Styles on African- American and Casuasian’s Suicidal Behaviors. J Youth Adolescence. 39(4): 357–369. 3. Koutek J, Kocourková J (2003). Sebevražedné chování [Suicidal Behaviour]. 1st ed. Praha: Portál. 127 p. (Czech). 4. Kriegelová M (2008). Záměrné sebepoškozování v dětství a adolescenci [Deliberate Self-destruction during Childhood and Adolescence]. 1st ed. Praha: Grada. 174 p. (Czech). 5. Máchová V, Průchová D, Velemínský M (2011). Sebevraždy seniorů. (Některé vnější vlivy a způsoby provedení sebevražd u seniorů) [Suicide in Senior Citizens. (Some external influences and the methods of suicide in senior citizens]. Prevence úrazů, otrav a násilí. 6(2): 154–161 (Czech). 6. Národní strategie prevence násilí na dětech v České republice 2008–2018 (NAP), Usnesení vlády ze dne 3. září 2008, č. 1139 [National Strategy to Prevent Violence against Children in the Czech Republic 2008–2018 (NAP), Government Resolution No. 1139 of 3 September 2008]. [online] 2008 [cit. 2011-5-3]. Available at: http://racek.vlada.cz/usneseni/usnweb. nsf/15F8712DDC155749C12574B800484403/$FILE/1139%20uv080903.1139.pdf (Czech). 7. Samm A et al. (2010). Suicidial Thoughts and Depresive Feelings amongst Estonian Schoolchildren: Effect of Family Relationship and Family Structure. Eur Child Adolesc Psychiatry. 19(5): 457–468. 8. Sdružení Linka bezpečí dětí a mládeže. 10 let Linky bezpečí [Safety Line Association. 10 years of the Safety Line]. [online] 2010 [cit. 2011-6-24]. Available at: http://www.linkabezpeci.cz/webmagazine/ kategorie.asp?idk=239 (Czech). 9. Svoboda M, Krejčířová D, Vágnerová M (2009). Psychodiagnostika dětí a dospívajících [Psychodiagnostics of Children and Adolescents]. 1st ed. Praha: Portál. 792 p. (Czech). 10. Vágnerová M (2005). Vývojová psychologie I [Developmental Psychology]. 1st ed. Praha: Karolinum. 468 p. (Czech). 11. Veselý M (2011). Vybrané kapitoly ze sociální patologie [Selected Chapters from Social Pathology]. 1st ed. České Budějovice: Jihočeská univerzita v Českých Budějovicích, Zdravotně sociální fakulta. 127 p. (Czech). 12. Vodáčková D et al. (2002). Krizová intervence I [Crisis Intervention]. 1st ed. Praha: Portál. 544 p. (Czech). 13. WHO, World Report on Violence against Children. [online] 2006 [cit. 2011-7-1]. Available at: http:// www.crin.org/docs/UNVAC_World_Report_on_Violence_against_Children.pdf

 Contact: Dominika Průchová, University of South Bohemia, Faculty of Health and Social Studies, Social Work Institute, České Budějovice, Czech Republic E-mail: [email protected]

263 Journal of Nursing, Social Studies, Public Health and Rehabilitation 3–4, 2011, pp. 264–269

MOTIVATION FOR USING ILLEGAL DRUGS AT FREETEKNO PARTIES

Alena Kajanová1, Aneta Klečacká2

1University of South Bohemia, Faculty of Health and Social Studies, České Budějovice, Czech Republic 2A student of MUNI in Brno, branch of study – social work, Czech Republic

Submitted: 2011-03-02 Accepted: 2011-09-12 Published online: 2011-12-15

Abstract The knowledge acquired about the freetechno subculture by the general public in the Czech Republic has been obtained exclusively through its negative image associated with consumption of socially illegal drugs as it is depicted in the mass media and which has also been substantiated with results of addictological and sociological surveys. The objective of our paper is to identify whether there is a connection between the type of drugs used at freetekno parties and the freetekno subculture in the sense of subjectively perceived connection between the type of used drugs and the specific type of a dance party. Another objective is to outline whether the possibility to buy/use a drug represents the priority motivation for visiting a party or only makes the atmosphere of an even as such complete. We selected the qualitative research, techniques of semi-structured interviews and participant observation in the party environment as the research method. The research set comprised of participants in randomly selected freetekno parties (N=10). The results of the research show that music and the overall atmosphere of an event with an accent on its tribal character are stated by respondents as the principal motivation for visiting a party. Respondents perceive drugs that are usually used there as connected with the subculture (or rather the subculture considers some drugs to be appropriate, while rejecting others). Hallucinogens and cannabinoids predominate among illegal drugs at freetekno parties. Although most respondents state they are also able to enjoy a party equally well without them, in their answers, they keep referring to drugs being the very thing creating the atmosphere of a dance party. ORIGINAL ARTICLE ORIGINAL Key words: subculture; freetekno; dance music; motivation; illegal drugs

INTRODUCTION country especially pervitin, LSD, GHB and other) (e.g. Saunders 1996). Dance music The professional as well as general public does not comprise any compact whole, it usually associate dance music not only consists of many trends creating individual with entertainment, but also with using subcultures, the best known among which of various types of socially acceptable and are techno, trance, house, drum and illegal drugs (cf. Tanec a drogy 2007... base in the Czech environment (Dorážka 2008). Thus, we talk about so called dance 1998), and furthermore such branches drugs (MDMA, but also stimulants; in our as the tekno that we pay our attention

264 Motivation for using illegal drugs at freetekno parties to in our paper. A subculture developed in for any targeted intervention, but also connection with a specific music style also understading of the life-style of a subculture expresses itself through a specific life style as such. (Hedbige 1981). Individual branches of dance The research is based on the bachelor thesis music and individual life styles that may titled “Freetekno a komerční technoscéna develop in relation to them then also bring z pohledu odlišnosti preferovaných drog” along specifics in using illegal drugs (Forsyth [Freetekno and the Commercial Technoscene et al. 1997), which are the special focus of from the Point of View of Differences among this paper. Socially accepted substances, i.e. Preferred Drugs] (Klečacká 2011). especially alcohol and nicotine, can be found at music events of probably all types and are comparably represented there (Tanec a drogy MATERIAL AND METHODS 2007... 2008). While for example the techno scene in various Czech (Tanec a drogy 2007... For the purposes of data collecting, with 2008) as well as foreign (Tossmann et al. 2001, respect to the specifics of the target set and Bogt et al. 2002) studies shows polymorphic to the objective and focus of the research, occasional using of ecstasy, marihuana and we selected the technique of semi-structured pervitine primarily, it is especially synthetic interviews based on prepared circles of and natural hallucinogens and marihuana questions and participant observation, that are found at participants in freetekno i.e. staying directly at a party with its par- parties (Kajanová and Pešek 2009). ticipants for several days. Information was The community built around freetekno, recorded by means of field notes that were which is based on the rave movement, is subsequently transcribed and analysed. known especially for its protest against Hence, they were research methods and commercial parties and the effort to return techniques corresponding to the combination to nature, tribal traditions and rituals of the sociological and ethnographic research (Wimmer 2006) and in the media discourse which is usually applied to study subcultures. due to the Czechtek festival (Kajanová 2010). Although data collecting for the purposes of Unannounced open-air parties lasting several the paper was conducted during one year, days were traditionally based on the DIY (do it authors had already been establishing contacts yourself) principle, i.e. in principle, they were with the research environment during several gatherings of freetekno fans around so called years before its beginning. soundsystems (mobile sound units). The The subjects of our research interest were party was thus financed from the funds raised randomly selected participants in freetekno by selling food and drinks that were offered parties held in the South Bohemia and West by individual soundsystems to their listeners, Bohemia regions (specifically, they were and admission was free for listeners (Wimmer parties in Borotín, Rožmitál pod Třemešínem 2006). and Růžené) from May to September 2009. The objective of our paper, or rather of the There were addressed ten male (N=5) research the paper is based on, is to identify and female (N=5) respondents willing to whether there is a connection between the testify, at the average age of 22 years. All type of drugs used at freetekno parties and respondents stated that they visited nearly the freetekno subculture in the sense of exclusively events of the same type as was subjectively perceived connection between the one where the interview took place, and the type of used drugs and the specific type of only exceptionally also other dance parties of a dance party. Another objective is to outline a different type. The most frequent range of whether and how important it is for people visits to parties by the interviewed was once a visiting a party to have an opportunity to week to once every two weeks (8 respondents), use a drug there and whether this represents while 2 respondents stated the frequency of the priority motivation for visiting a party once a month. However, we assume a higher or only makes the atmosphere of an even as frequency of visits in summer months when such complete. Understanding the connection the research was conducted. between used drugs and a specific type of At the same time, all the interviewed subculture represents not only a precondition identified themselves with the freetekno

265 Alena Kajanová, Aneta Klečacká subculture or actually stated they felt being a never tried it so he could not imagine how he part of the subculture. would be able to enjoy himself. The other respondents stated that a good party did not a priori mean using a drug: “It is definitely possible. I thought it wasn’t, that RESULTS drugs make a part of it somehow as they enable better distraction and perceptions Motivation for visiting a party and the inspired by the music, but it’s not like this. connection between a “good party” and I experienced a party without any drugs, drugs including legal ones, and it was even better First of all, we studied the motivation of than the ‘drug’ ones. One pays attention to respondents for visiting parties, while other things and is there for oneself. When it monitoring whether drug using would be is a quality party, I think it can be enjoyed mentioned among the motivations. equally well with or without drugs.” However, As we presumed, the common deno- they mostly referred to their “saturation” with minator of answers provided by most socially acceptable drugs, especially with respondents was music. Seven out of the ten alcohol. “Yes, it is possible, I have been doing respondents stated that music comes first as it like this for quite a long time, I can do with their motivation. The remaining respondents a bottle of rum or vodka, and it makes no stated the “specific atmosphere” related to the difference to me...” subculture as such and was also mentioned If we work on the hypothetical assumption in the other 6 responses. This included a that participants in a party visit it because it combination of the following responses: “I is easier to obtain illegal drugs there (among feel free there. Without any restrictions.” other things), it will be good to focus on the This was followed up with freedom, fact whether participants look for drugs meeting new people or, as the case may be, directly at a party or bring them in from meeting the existing acquaintances: another place. Respondents usually answered “The atmosphere, mood, people, ‘to clear to a question asked in this manner using a one’s head’, visualisations, decorations, dogs, combination of both possibilities, i.e. drugs when a place is well chosen, the ‘spirit’ of the are available at a party, however this is not a place, but actually the party as the whole, all required condition: its parts fitting together.” “Well, you can mostly come by something, “Of course, good music and sound but it’s a question what you want to get. quality. Then I also like meeting new people, LSD for example, it’s not a problem, but you video projections with crazy hallucinations wouldn’t get mushrooms so easily, so must appearing there which make me quite zonked bring them with you...,” or their quality is not out at the end, and then any diversity of required: “When you don’t know the people, colours, visualisations and decorations...” you don’t know what you may buy from Respondents perceived the “specific them, I wouldn’t like to rely on that...” atmosphere” as the know-how of freetekno All our respondents stated that mostly events, and although their responses were they bring some drugs along with them or differentiated to a certain extent, the main they know somebody at a party who will have characteristics were repeatedly mentioned in them. most of them. The association of a drug did not appear in Drugs used at a party and reasons for any of the responses to the question about the their selection reason for visiting an event. As regards specific types of drugs used at We were furthermore ascertaining the parties, respondents assessed their scene connection between the motivation for subjectively as being different from other visiting a party and drug using by asking a types of parties. We asked about both the question whether it was possible to enjoy a specific party and regular using of drugs at good party without illegal drugs. A negative parties in general. Answers to the questions answer was given by one respondent only, and were largely identical – respondents stated he furthermore referred to the fact that he had they had their “favourite drugs” they usually

266 Motivation for using illegal drugs at freetekno parties used at parties and that they had also used or link between the party life and everyday life. planned to use at the specific party, therefore When mentioning illegal drugs, respondents we do not differentiate the answers provided talked about their weekend using and their herein under. The reasons mostly given by connection with a party and the subculture. respondents for using a specific drug (in Seven respondents furthermore mentioned response to the question “Why do you use using marihuana at a party: “Recently, I the specific drug at a party?”) were that it is have cannabis instead of alcohol. One is not appropriate for a party or that using a drug is hungover, effects on health are not so bad...,” a standard there. while three of them also used it outside a Generally, alcohol was prevailing (8 out party environment, i.e. regularly. Marihuana of 10 respondents): “I perhaps don’t know was perceived as a substance comparable to anybody who would not have at least some alcohol as regards frequency of its using. beer or a shot of something at weekends. Ecstasy was mentioned by 5 respondents. This is simply a part of life, and so of a party, While four of them, nevertheless, did not too.” Alcohol (together with nicotine, and in find this drug typical for the freetekno scene: several cases with marihuana in addition to “Ecstasy and pervitin are rather used by it) also belonged among the most frequent people from commercial events, at clubs so polymorphously used substance, specifically as they would be able to stay dancing until in combination with anything, or rather the morning...,” one respondent contrarily respondents stated they did not think about stated that ecstasy as well as hallucinogens combining alcohol with another drug (as were more appropriate for outdoor events: opposed to combinations of other types of “... it’s simply more pleasant to experience substances that we however did not pay closer any hallucinogens and MDMA under the attention to in our research). open sky than in a crowded club at 40 °C...” The same number, i.e. 8 respondents, Stimulants (or more precisely pervitin furthermore stated hallucinogens (natural – and, in one case, cocain appeared in three psilocybe mashrooms as well as synthetic – responses. One respondent stated that he LSD). The reasons given for using them had used opiates (specifically fentanyl) at a included the nature which is a more pleasant party several times. The respondents did not environment for a trip than an enclosed connect these drugs with the subculture at premises of a club: “... because it’s great all and neither did the drugs belong among to have visual or auditory hallucinations substances frequently or commonly used somewhere in the countryside where you at parties. On the other hand, contrary to have places where you can hide away, and these respondents, others stated that they when it’s just the case it starts working badly, had a negative attitude to the abusing of it’s not so terrible as it would be somewhere pervitin at the freetekno scene because of the in a club. But the good thing is you enjoy disintegration of traditional subculture values everything and examine the nature and in participants caused by this substance. It is countryside and animals and everything often the case that leaflets promoting future is somehow different...,” or the “specific similar events contain the “pervitin kills atmosphere” of a party that has already been tekno” phrase. mentioned herein above, completed with visualisations and other sensual stimuli, and presence of nice people, acquaintances: “It’s DISCUSSION also about people who are at the party, and about the atmosphere...” The results of our research, although we Another socially acceptable drug, nicotine, are aware of its limits with respect to its was regularly used by 7 respondents. We qualitative character and the random selection consider interesting that cigarettes were of respondents, provided information on evaluated as a persisting bad habit, addiction, the abusing of drugs which corresponds while none of respondents described other to the results of quantitative surveys (e.g. used substances as an addiction: “And tobacco The National Report... 2005), i.e. these is just a disgusting addiction I can’t get rid include especially alcohol and nicotine, and of.” Nicotinism thus represented kind of a marihuana, hallucinogens and MDMA from

267 Alena Kajanová, Aneta Klečacká among illegal drugs (cf. for example Kučera depicting such parties as events where drugs 2008). Here we would however like to draw are easily available. On the other hand, Weber attention to the fact that the drug scenes in (1999) and Bednaříková (2010) state music the Czech Republic and abroad are difficult and meeting friends to be other reasons for to be compared, although the type of a party joining a party. In other words, parties are is the same, because drugs available there are associated with a higher occurrence of drugs, generally different. For example ketamine, however they are not the only reason for which is commonly used among French and visiting a party. British ravers, belongs among substances that are used relatively less frequently in the Czech Republic. Nevertheless, participants subjectively perceive the preference of CONCLUSION these types of drugs to be connected with their subculture that creates the specific The outcomes of our research have produced atmosphere. The above specified preference several interesting findings that, although we was also expressed in contrast to hypothetical do not want to generalize them, attest more reasons for non-preference of the respective to the fact that there is a connection between substance in a club environment. drug using and a specific type of dance parties. Illegal substances, especially pervitin, or Participants to freetekno parties mention the substances that visitors identify as typical atmosphere consisting of largish amount for other types of dance events – for example of stimuli – be it a location, the feeling of ecstasy as a club drug (cf. Weber 1999, stating freedom, nature, people or drugs. They crack and intravenous use in general to be perceive parties in a complex manner, in the the only dugs not acceptable at the rave spirit of tribality that is one of the principles scene) occur at freetekno parties as much as of this subculture (cf. Wimmer 2006). This the preferred substances. This finding may specific character as well as the character of also be related to the outcomes of the Tanec an event may then determine types of drugs a drogy 2007... (2008) study, stating that (or rather groups of drugs) that are used at despite the high prevalence of using various parties. Although respondents, in most cases, types of drugs, including pervitin, presence were able to imagine a good party without of problematic users among participants in illegal drugs, they emphasized that at least dance parties is low. presence of socially acceptable drugs – alcohol For our respondents, drug use or rather and tobacco – was necessary. availability of drugs on the freetekno scene Apart from the area that was the subject did not represent the primary reason for matter of our research, we came to no visiting this type of events, which is a finding less important outcomes concerning self- contradicting, to some extent, for example identification with the subculture or rather McCaughan et al. (2005) who state the delimitation of the subculture in opposition to presence of so called chemi-kids at parties others (which Hedbige /1981/ considers to be who participate in such events primarily so as the very characteristic feature of a subculture) they could get drugs there. At the same time, or as this was summarized by one of the the authors consider their presence to result respondents who noted: “And write there we from presentation of such events in the media, are not the commercial tweakers from clubs.”

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1. Bednaříková V (2010). Specifika užívání drog na freetekno parties [Specifics of Using Drugsat Freetekno Parties]. Olomouc: Univerzita Palackého. Diplomová práce (Czech). 2. Bogt TT, Engels R, Hibbel B, Wel FV, Verhagen S (2002). “Dancetasy”: Dance and MDMA use in Dutch youth culture. Contemporary Drug Problems. 29: 157–173. 3. Dorážka P (1998). Cesta kolem světa rychlostí zvuku [Journey around the World at the Speed of Sound]. In Weiss T: Beaty, bigbeaty, breakbeaty: průvodce moderní hudbou 90. let [Beats, Bigbeats, Breakbeats, the Guide to Modern Music of the 1990s]. Praha: Maťa. 321 p. (Czech).

268 Motivation for using illegal drugs at freetekno parties

4. Forsyth AM, Barnard M, McKeganey NP (1997). Musical preference as an indicator of adolescent drug use. Addiction. 92(10): 1317–1325. 5. Hedbige D (1981). Subculture: The Meaning of Style. London: Methuen. 6. Kajanová A (2010). Subkultury mládeže v České republice [Youth subcultures in the Czech Republic]. Prevence. 4(7): 8–9, 18 (Czech). 7. Kajanová A, Pešek M (2009). Řeč symbolů freetekno komunity [The Language of Symbols of the Freetekno Community]. Psychologie dnes. 15(7): 34–37 (Czech). 8. Klečacká A (2011). Freetekno scéna a komerční technoscéna z pohledu odlišnosti preferovaných drog [The Freetechno Scene and the Commercial Techno Scene from the Point of View of Differences between Preferred Drugs]. Bakalářská práce. České Budějovice: ZSF JU (Czech). 9. Kučera M (2008). Technoparty (popis aktuálního stavu předmětného sociálního jevu, shrnutí a porovnání názorů příznivců a odpůrců techno hnutí, formulace možností společensky přijatelných řešení) [Technoparty (Description of the Current Situation of the Social Phenomena in Question, Summary and Observation of Opinions Expressed by Supporters as well as Opponents of the Movement, Formulation of Possibilities of Socially Acceptable Solutions)]. In Velemínský M, Sr., Studenovský P: Rukověť pro poskytovatele a zadavatele sociálních služeb v oblasti problematiky dětí a mládeže [Handbook for Providers and Contracting Authorities of Social Services in the Area of Issues Related to Children and Young People]. České Budějovice: ZSF JU, pp. 72–87 (Czech). 10. McCaughan JA, Carlson RG, Falck RS, Siegal HA (2005). From “Candy Kids” to “Chemi-Kids”: A typology of young adults who attend raves in the midwestern United States. Substance Use & Minuse. 40: 1503–1523. 11. National report to the EMCDDA by the Reitox National Focal Point, France, New Development, Trends and in-depth information on selected issues. Paris: OFDT, 2005. 12. Saunders N (1996). Extáze a technoscéna [Ecstasy and the Technoscene]. Brno: Jota, p. 314 (Czech). 13. Tanec a drogy 2007 – výsledky studie (2008) [Dance and Drugs 2007 – Outcomes of the Study]. [online]. [cit. 1. 8. 2010]. Available at: WWW: http://www.drogy- info.cz/index.php/info/ilegalni_ drogy/tanecni_drogy/tanec_a_drogy_2007_vysledky_studie (Czech). 14. Tossmann P, Boldt S, Tensil MD (2001). The Use of Drugs within the Techno Party Scene in European Metropolitan Cities. Eur Addict Res. 7–8: 2–23. 15. Weber TR (1999). Raving in Toronto: peace, love, unity and respect in transition. Journal of youth studies. 2(3): 317–335. 16. Wimmer L (2006). Freetekno a Czechtek 2005 [Freetekno and Czechtek 2005]. Praha: FSVUK, p. 141 (Czech).

 Contact: Alena Kajanová, University of South Bohemia, Faculty of Health and Social Studies, Jírovcova 24, 370 01 České Budějovice, Czech Republic E-mail: [email protected]

269 Journal of Nursing, Social Studies, Public Health and Rehabilitation, Vol. 2, No. 3–4, 2011, pp. 133–274

INFORMATION FOR CONTRIBUTORS

Journal of Nursing, Social Studies, Public Health and Rehabilitation is an international, peer reviewed transdisciplinary journal covering the fields of nursing, health and social sciences, public health, social medicine, preventive medicine and related areas for RAPID publication of Original Papers, Review Articles, Case Reports, and other contributions from all the fields covered by Journal of Nursing, Social Studies, Public Health and Rehabilitation.

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INFORMATION FOR CONTRIBUTORS INFORMATION the editor will always respect this wish unless the submitted and accepted manuscript has already passed publishing procedures. The original material of rejected articles will be returned to the authors.

270 Information for contributors

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COPYRIGHT It is a condition of publication that the authors transfer the world copyright of their manuscripts to the Journal of Nursing, Social Studies, Public Health and Rehabilitation. All manuscripts should therefore be accompanied by a signed statement that the article is original, is not under consideration or has not been previously published in another journal. Nevertheless, authors will be entitled to publish any part of their paper elsewhere without permission, provided the usual acknowledgments and reference to the ORIGINAL source. Authors will be notified if a request to publish a part or whole of their paper is received. Illustrations, figures, tables or quotations from other publications are already copyrighted and can be reproduced only with written permission from the copyright owner. Written permission to use these should accompany the manuscript. ETHICS The Editors and the Publisher support the principles of the Declaration of Helsinki of 1975, as revised in 1983, and expect that the authors of papers submitted to the Journal will have obtained ethical consent and followed those legal and regulatory requirements for human experimentation with drugs, including informed consent, according to procedures which apply in their institution and country. (When reporting experiments on animals, indicate whether the institution’s or a national research council’s guide for, or any national law on, the care and use of laboratory animals was followed.)

LENGTH OF PAPERS/MANUSCRIPT PAGES No limitations to the total length of their paper, independently of the category (Original papers, Review papers, Case Reports, etc.) will be applied. Manuscripts should be typed double-spaced on numbered pages, two manuscript pages is approximately one printed page. Organization of the Manuscript: • Authors are advised to write clearly and simply, prepare the text without any graphical formatting (different types and sizes of fonts, dividing of text, page frames, bullet lists, incorporated graphs, pictures, macros etc.). Page size should be set to A4, 1.5 line spacing, 60 characters per line and 30 lines per page.Recommended size of font is 12, type of font Times New Roman. • Distinguish consistently between numbers 1 and 0 and letters O and I. • Use only parenthesis ( ), square brackets are used only for references citing. • Always add space after punctuation, never before. • ENTER use only when starting new paragraph. • Use only italic or bold formatting for text highlighting; do not underline or change the character spacing of the text. • When numbering paragraphs or lines do not use MS Word’s function „numbered lists“. • All pages should be numbered consecutively in the top right-hand corner using Arabic numerals, beginning with the title page. • All additional material must be added after the main body of manuscript (i.e. after the references), page size A4, 1.5 line spacing; 60 characters per line and 30 lines per page. • Manuscript should be sent to the Editor-in-chief in the electronic version on CD, DVD or by an e-mail.

PRESENTATION The pages should be numbered consecutively, beginning with the Title page. The sections of the manuscript should be in following sequence: Title page, Abstract (structured for Original papers and non-structured for Review Articles), Key words, Abbreviations, Main text (Introduction, Material and methods, Results and Discussion, Conclusion), Acknowledgments, References, Tables and Figures. Particular attention should be taken to ensure that the manuscript adheres to the Instructions for Authors of the Journal of Nursing, Social Studies, Public Health and Rehabilitation in all respects. The use of footnotes is not permitted (numbered comments/footnotes can be added at the end of the main text, before the Reference section). The Editors reserve the right to alter manuscripts whenever necessary to make them conform to the stylistic and bibliographic conventions of the Journal of Nursing, Social Studies, Public Health and Rehabilitation.

271 Information for contributors

TITLE PAGE Title page of the manuscript should contain: 1. The title itself. 2. The name(s) of the author(s): first name(s) spelled out, family name and highest academic degree. 3. Author’s Affiliations: The name(s) of the department(s) or institution(s) from which the study originated. 4. Corresponding Author: The name and full address, including telephone and fax numbers, e-mail address(es) and other useful information of the corresponding author. The authors are obliged to inform the publisher immediately about any change of thein fax, telephone, e-mail and ordinary mail address by e-mail: [email protected] 5. “Running headline”, a maximum of 40 characters, including word spaces.

ABSTRACT and KEY WORDS Abstract and Key words follow directly after the Title page (no extra page) A structured abstract (Original Articles) and non-structured abstract (Review papers) not exceeding 250 words should state what was done – objectives, methods, results, discussion and conclusion. Additional headings may be used. At least 5 to 10 key words should be used, which correspond to MESH headings by Medline. The key words should be separated by semicolons. The key words will be included in the Subject Index of the volume. The next section can start directly after this on the same page.

ABBREVIATIONS AND UNITS List of abbreviations and symbols used and spell them out in full. Abbreviations and symbols must be standard, and SI units (The International System of Units) should be used throughout. Drugs should be described by thein official names, but trade names should be indicated in brackets (the first time a drug is quoted in the main text).

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RESULTS Do not repeat in the text all the data displayed in the tables or illustrations; only important observations should be emphasized or summarized.

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272 Information for contributors

CONCLUSION The conclusions should be clearly linked with the objectives of the study.

REFERENCES Responsibility for the accuracy of bibliographic citations lies entirely with the authors. Citations in the text: Please ensure that every reference cited in the text is also present in the reference list (and vice versa). Unpublished results and personal communications are not recommended in the reference list, but may be mentioned in the text. If these references are included in the reference list they should follow the standard reference style of the journal and should include a substitution of the publication date with either “Unpublished results” or “Personál communication”, Citation of a reference as “in press” implies that the item has been accepted for publication. All citations in the text should refer to: 1. Single author: the author’s name (without initials, unless there is ambiguity) and the year of publication; 2. Two authors: both authors’ names and the year of publication; 3. Three or more authors: first author’s name followed by “et al.” and the year of publication.

Citations may be made directly (or parenthetically). Groups of references should be listed first alphabetically, then chronologically.

Examples: “reports and open studies are available (Norton 2000, Edwards et al. 2001. Krusz and Stillman 2001). Mathew et al. (2000) used a fixed and relatively low dosage of valproate and accomplished...”

In the Reference List: References should be numbered and arranged first alphabetically and then further sorted chronologically if necessary. More than one reference from the same author(s) in the same year must be identified by the letters “a”, “b”, “c”, etc., placed after the year of publication. The titles of journals should be abbreviated according to the style used in the Index Medicus.

Examples of the correct form of references: 1. Standard journal article Michalka P, Novotný J, Hassoun OE, Jakubovský J, Slobodníková L, Vician M, West DJ, Jr. (2008). Morphological relationship between macro- and microorganism. Coccidia in the appendix of rabbit. Journal of Nursing, Social Studies and Public Health. 9/2: 140–150.

Bužgová R (2008). Spokojenost seniorů s institucionální péčí v Moravskoslezkém kraji. Kontakt. 10/2: 257–263.

2. Books and other monographs a) Personal author(s): Ringsven MK, Bond D (1996). Gerontology and leadership skills for nurses. 2nd ed. Albany (NY): Delmar Publishers. 358 p. b) Editor(s) as author(s): Norman IJ, Redfern SJ, editors (1996). Mental health care for elderly people. New York: Churchill Livingstone. 298 p. c) Chapter in a book: Phillips SJ, Whisnant JP (1995). Hypertension and stroke. In Laragh J Brenner BM, editors: Hypertension: pathophysiology, diagnosis, management. 2nd ed. New York: Raven Press, pp. 465–478. d) Conference proceedings: Kimura J, Shibasaki H, editors (1996). Recent advances in clinical neurophysiology. Proceed ings of the 10th International Congress of EM and Clinical Neurophysiology; Oct 15–19, 1995; Kyoto, Japan. Amsterdam: Elsevier. e) Conference paper: Bengtsson S, Solheim BG (1992). Enforcement of data protection, privacy and security in med ical informatics. In Lun KC, Degoulet P, Piemme TE, Rienhoff O, editors: MEDINFO 92. Proceedings of the 7th World Congress on Medical Informatics; Sept 6–10, 1992; Geneva, Switzerland. Amsterdam: North- Holland. p. 1561–1565.

273 Information for contributors f) Dissertation: Kaplan SJ (1995). Post-hospital home health care: the elderly’s access and utilization (dissertation). St. Louis (MO): Washington Univ.

3. Electronic sources Link / URL - World Wide Web (WWW) Sites: Národní rozvojový program mobility pro všechny [online]. 2004 [cit. 2005-02-21]. Dostupné z: http:// www.nrzp.cz/doc/NRPM.doc.

Article in an online periodical: Pomahač R (2003). Etika ve veřejné službě pro nové tisíciletí – recenze. Veřejná správa [online], no 19 [cit. 2003-05-07]. Dostupné z: http://www.mvcr.cz/casopisy/s/2003/0019/recenze.html

TABLES AND FIGURES (Figures, illustrations, graphs, etc.) Tables and Figures should be numbered consecutively and provided with a concise title and legend. Be sure that each table and figure is cited in the text. All tables and figures should be specifically referred to in the text, e.g. Table 3, Figure 3. Figures/illustrations, etc. must send as a high quality scan (.tiff, .eps or .jpg in high resolution, original Illustrator file .ai or PowerPoint file), electronically by email. All figures (figures, illustrations, photographs, representational drawings, graphs, etc.) must be professionally executed; freehand or typewritten lettering is unacceptable. Figures and Tables including the legends should be placed at the end of the document or in a separate file (not inserted in the main text). Figures must be sent electronically as separate attachments: a) Bitmap raster images as .TIF, BMP, GIF or .EPS are accepted if the resolution 300 dpi for published figure size is provided. Files can be compressed with WinZip. JPG files are accepted if saved in high quality compression only. b) Excel and PowerPoint files are accepted (PC compatible) as separate files by email. All exceptions to the above should be agreed upon after contact with editor-in chief.

ACKNOWLEDGMENTS The scientific and material contributions of others to the work should be acknowledged. Any grant supports should be listed and permission for reproduction of Publisher material acknowledged. Authors are responsible for obtaining written permission from anyone acknowledged by name. The acknowledgments will be Publisher as an appendix to the text.

PROOFS Before publication the correspondent author will receive a copy of the final version of the paper, which should be read carefully for errors and returned promptly. Proofs will be sent for the correction of typographic errors only. No other changes will be accepted. Proofs not returned within 7 days will be considered as approved by the author(s).

DOCTORAL THESES AND DISSERTATIONS IN BRIEF This Journal encourages the submission of important works by young investigators, researchers and practitioners. In this section the Editor wishes to recognize innovative research conducted during graduate and postgraduate studies. Each doctoral thesis or dissertation should contain an abstract and provide a concise synopsis (10 manuscript pages maximum) of the major findings presented in the final version.

LETTERS TO THE EDITOR The Journal of Nursing, Social Studies, Public Health and Rehabilitation has a section carrying comments, questions, or criticism about articles that have been published and where the original authors can respond. This section takes the form of Letters to the Editor, where also other topics and views from readers may be published and discussed.

SUPPLEMENTS Monographs or series of articles that have undergone regular scientific review, university approved theses, conference proceedings, symposia on related issues or topics, etc. may be printed as supplements to the Journal of Nursing, Social Studies, Public Health and Rehabilitation. Supplements are published as a separate issues of the Journal and are negotiated in advance with the Editor-in-Chief, and must be prepaid prior to publication.

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